Provider Demographics
NPI:1770998551
Name:MOULDER, LANE ALISON
Entity type:Individual
Prefix:MRS
First Name:LANE
Middle Name:ALISON
Last Name:MOULDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8908
Mailing Address - Country:US
Mailing Address - Phone:443-996-9947
Mailing Address - Fax:
Practice Address - Street 1:1012 NORTH POINT RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-3338
Practice Address - Country:US
Practice Address - Phone:443-216-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD298521700Medicaid