MEDICARE: LYNNE A MOULTON LICSW

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	1041C0700X	Clinical Social Worker	SW1059361	MA

General Provider Information

NPI Number	:	1518025212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNNE A MOULTON LICSW

Provider Business Mailing Address
First Line	:	254 OCEAN ST
Second Line	:
City	:	LYNN
State	:	MA
Zip	:	01902
Country	:	US
Telephone Number	:	781-595-5504
Fax Number	:	781-860-7636

Provider Business Practice Location Address
First Line	:	1040 WALTHEN ST
Second Line	:
City	:	LEXINGTON
State	:	MA
Zip	:	02420
Country	:	US
Telephone Number	:	781-860-0570
Fax Number	:

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

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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