Healthcare Provider Details

I. General information

NPI: 1871752097
Provider Name (Legal Business Name): MARY KATHERINE MOULTON M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY MOULTON MS, LPC

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6372 S 80TH EAST AVE APT A
TULSA OK
74133-3847
US

IV. Provider business mailing address

6372 S 80TH EAST AVE APT A
TULSA OK
74133-3847
US

V. Phone/Fax

Practice location:
  • Phone: 918-200-2037
  • Fax: 918-818-3973
Mailing address:
  • Phone: 918-200-2037
  • Fax: 918-818-3973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4953
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0024311
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0024311
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4953
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4953
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0024311
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: