Provider Demographics
NPI:1215070677
Name:MOULTON, TECKLA P (PT)
Entity type:Individual
Prefix:MRS
First Name:TECKLA
Middle Name:P
Last Name:MOULTON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:TECKLA
Other - Middle Name:
Other - Last Name:PERSONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:231 SUTTON ST
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-1620
Mailing Address - Country:US
Mailing Address - Phone:978-685-8059
Mailing Address - Fax:978-685-6421
Practice Address - Street 1:231 SUTTON ST
Practice Address - Street 2:SUITE 1C
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-1620
Practice Address - Country:US
Practice Address - Phone:978-685-8059
Practice Address - Fax:978-685-6421
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2668225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0397903Medicaid
MAMOY65938OtherBLUE CROSS
MAMOY65938OtherBLUE CROSS