Provider Demographics
NPI:1992300206
Name:MOUTON, HAYWARD JOSEPH (LCSW)
Entity type:Individual
Prefix:
First Name:HAYWARD
Middle Name:JOSEPH
Last Name:MOUTON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1672 PARK AVE APT 3D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-4653
Mailing Address - Country:US
Mailing Address - Phone:332-223-9613
Mailing Address - Fax:
Practice Address - Street 1:1672 PARK AVE APT 3D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-4653
Practice Address - Country:US
Practice Address - Phone:332-223-9613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040135601041C0700X
MD233041041C0700X
DCLC500822681041C0700X
NY0988391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC015230466Medicaid