Healthcare Provider Details

I. General information

NPI: 1770998551
Provider Name (Legal Business Name): MRS. LANE ALISON MOULDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 03/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 NORTH POINT RD
BALTIMORE MD
21224-3338
US

IV. Provider business mailing address

1806 EDGEWOOD RD
TOWSON MD
21286-8908
US

V. Phone/Fax

Practice location:
  • Phone: 443-216-4800
  • Fax:
Mailing address:
  • Phone: 443-996-9947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC8440
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: