Healthcare Provider Details

I. General information

NPI: 1770636698
Provider Name (Legal Business Name): DONNA LYNN MOULTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HEALTH SERVICES DR
DEKALB IL
60115-9637
US

IV. Provider business mailing address

1838 BROWER PL
SYCAMORE IL
60178-3029
US

V. Phone/Fax

Practice location:
  • Phone: 815-758-8616
  • Fax:
Mailing address:
  • Phone: 815-899-0682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: