Provider Demographics
NPI:1285669200
Name:MOULTON, JOHN L III (PH D)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:L
Last Name:MOULTON
Suffix:III
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 1381
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531
Mailing Address - Country:US
Mailing Address - Phone:707-465-1000
Mailing Address - Fax:
Practice Address - Street 1:5905 LAKE EARL DRIVE
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531
Practice Address - Country:US
Practice Address - Phone:707-465-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20637103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist