Provider Demographics
NPI:1770452054
Name:MOULTON, TAYLOR
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:MOULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 DUNN AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-3214
Mailing Address - Country:US
Mailing Address - Phone:307-314-9789
Mailing Address - Fax:
Practice Address - Street 1:2321 DUNN AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-3214
Practice Address - Country:US
Practice Address - Phone:307-314-9789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYCMHW-076101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor