Provider Demographics
NPI:1104918416
Name:MOULTON, DAWN (RPT)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4302 ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55804-2114
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39 N 25TH ST E
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5269
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5635225100000X
MN1869225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6411503OtherMEDICA
WI41810700Medicaid
MNHP25224OtherHEALTH PARTNERS
MN15D94MOOtherBCBS
MN15D94MOOtherBCBS