Healthcare Provider Details

I. General information

NPI: 1417218975
Provider Name (Legal Business Name): YVETTE MOULTON LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3911 FAIRVIEW AVE
BALTIMORE MD
21216-1229
US

IV. Provider business mailing address

3911 FAIRVIEW AVE
BALTIMORE MD
21216-1229
US

V. Phone/Fax

Practice location:
  • Phone: 443-500-0258
  • Fax:
Mailing address:
  • Phone: 443-500-0258
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLC6342
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: