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General NPI Number Information
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NPI Number | 1760727978
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Entity Type | Organization
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Legal Business Name | MOOSILAUKE VISIONS, INC.
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Dates
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Enumeration Date | 11/29/2012
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Last Update Date | 11/15/2024
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Provider Practice Location Address
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Address Line | 23 S MAIN ST STE 2A
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City | HANOVER
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State | NH
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Zip | 03755-2075
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Country | US
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Telephone | 603-691-3435
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Fax |
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Provider Business Mailing Address
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Address Line | 633 NH ROUTE 10 PO BOX 325
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City | ORFORD
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State | NH
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Zip | 03777
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. JAY WOLTER
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Credential |
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Telephone | 603-359-9044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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