Provider Demographics
NPI:1720532211
Name:MOULD, MEGAN SUE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:SUE
Last Name:MOULD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MEGAN
Other - Middle Name:SUE
Other - Last Name:EUSTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:1940 HARRISON AVENUE
Mailing Address - Street 2:EMERALD COAST BEHAVIORAL HOSPITAL
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-6755
Mailing Address - Country:US
Mailing Address - Phone:850-763-0017
Mailing Address - Fax:850-763-4248
Practice Address - Street 1:340 MAGNOLIA CIR
Practice Address - Street 2:
Practice Address - City:TYNDALL AFB
Practice Address - State:FL
Practice Address - Zip Code:32403-5604
Practice Address - Country:US
Practice Address - Phone:850-283-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW127781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical