MEDICARE: KRISTIN MOULTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	121626-13	IL

General Provider Information

NPI Number	:	1447823695
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN MOULTON

Provider Business Mailing Address
First Line	:	6700 N GREENVIEW AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4208
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3640 W FILLMORE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4309
Country	:	US
Telephone Number	:	773-290-5891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2021
Last Update Date	:	09/30/2024

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