Healthcare Provider Details

I. General information

NPI: 1427427616
Provider Name (Legal Business Name): LAURA MOULDER LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N 13TH ST
PHOENIX AZ
85034-1111
US

IV. Provider business mailing address

18843 N 16TH PL
PHOENIX AZ
85024-2428
US

V. Phone/Fax

Practice location:
  • Phone: 602-523-8965
  • Fax:
Mailing address:
  • Phone: 845-913-5968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number073275-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: