Provider Demographics
NPI:1932767548
Name:MOULT, ANDREA NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:MOULT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:COMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1459 CLOVER RD
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-1102
Mailing Address - Country:US
Mailing Address - Phone:717-364-4686
Mailing Address - Fax:
Practice Address - Street 1:1700 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7529
Practice Address - Country:US
Practice Address - Phone:717-272-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-30
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0168541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty