Provider Demographics
NPI:1871752097
Name:MOULTON, MARY KATHERINE (MS)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:KATHERINE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:K.K.
Other - Middle Name:
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5327 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74112-1411
Mailing Address - Country:US
Mailing Address - Phone:918-850-6728
Mailing Address - Fax:
Practice Address - Street 1:231 E GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-2436
Practice Address - Country:US
Practice Address - Phone:918-825-1405
Practice Address - Fax:918-825-1406
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health