Provider Demographics
NPI:1407676265
Name:MOULDS, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MOULDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 WOODLAND AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-1965
Mailing Address - Country:US
Mailing Address - Phone:319-360-8213
Mailing Address - Fax:
Practice Address - Street 1:2100 WESTOWN PKWY STE 230
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-1539
Practice Address - Country:US
Practice Address - Phone:515-531-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA127576101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health