Provider Demographics
NPI:1154137933
Name:MOULTON, ELIZABETH RUTH-ANNE (PSYS)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:RUTH-ANNE
Last Name:MOULTON
Suffix:
Gender:F
Credentials:PSYS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 N FEDERAL HWY APT 415
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33306-1086
Mailing Address - Country:US
Mailing Address - Phone:419-340-8569
Mailing Address - Fax:
Practice Address - Street 1:21300 RUTH AND BARON COLEMAN BLVD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1757
Practice Address - Country:US
Practice Address - Phone:561-852-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1924103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool