Doctor Name: | BRYAN RICHARD MOULTON |
NPI Number: | 1659678365 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | LPC |
License Number: | 6200010-6004 |
Business Practice Address: | 240 E 300 N Ephraim, UT - 846271228 |
Business Phone Number: | 4358516733 |
Business Fax Number: | |
Mailing Address: | 240 E 300 N, EPHRAIM |
State: | UT |
Postal Code: | 846271228 |
Phone Number: | 4358516733 |
Fax Number: | |
NPI Enumeration Date: | 02/15/2011 |
NPI Last Update Date: | 02/15/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YP2500X |
License Number: | 6200010-6004 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | UT |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Professional |
Taxonomy Definition: |