Provider Demographics
NPI:1790896405
Name:MULDER, CONSTANCE JOYLYN (LISW-S, LICDC-CS)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:JOYLYN
Last Name:MULDER
Suffix:
Gender:F
Credentials:LISW-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 83
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-0083
Mailing Address - Country:US
Mailing Address - Phone:740-456-7079
Mailing Address - Fax:
Practice Address - Street 1:7048 FRONT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-7103
Practice Address - Country:US
Practice Address - Phone:740-456-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH923289101YA0400X
OH00087491041C0700X
WVDP009444611041C0700X
KY35371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)