MEDICARE: MRS. DIANNE MOULDER M.ED., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	C5156	OH

General Provider Information

NPI Number	:	1275790586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANNE MOULDER M.ED., P.C.

Provider Business Mailing Address
First Line	:	1303 W MAPLE ST
Second Line	:	STE. 103
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2858
Country	:	US
Telephone Number	:	330-966-8677
Fax Number	:	330-966-6511

Provider Business Practice Location Address
First Line	:	1303 W MAPLE ST
Second Line	:	STE. 103
City	:	NORTH CANTON
State	:	OH
Zip	:	44720-2858
Country	:	US
Telephone Number	:	330-966-8677
Fax Number	:	330-966-6511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	05/22/2008

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