Healthcare Provider Details

I. General information

NPI: 1790896405
Provider Name (Legal Business Name): CONSTANCE JOYLYN MULDER LISW-S, LICDC-CS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7048 FRONT ST
PORTSMOUTH OH
45662-7103
US

IV. Provider business mailing address

PO BOX 83
WHEELERSBURG OH
45694-0083
US

V. Phone/Fax

Practice location:
  • Phone: 740-456-7079
  • Fax:
Mailing address:
  • Phone: 740-456-7079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number923289
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0008749
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberDP00944461
License Number StateWV
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3537
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: