Provider Demographics
NPI:1992715668
Name:MOULTRIE, SUE B (LCSW)
Entity type:Individual
Prefix:
First Name:SUE
Middle Name:B
Last Name:MOULTRIE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SAND MOUNTAIN DR., NW
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35950-0859
Mailing Address - Country:US
Mailing Address - Phone:256-878-3809
Mailing Address - Fax:256-878-8022
Practice Address - Street 1:123 SAND MOUNTAIN DR NW
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35950-1647
Practice Address - Country:US
Practice Address - Phone:256-878-3809
Practice Address - Fax:256-878-8022
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1447C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051532527OtherBCBS
AL051551556Medicaid
AL631250107003OtherTRICARE
S76653Medicare UPIN
AL631250107003OtherTRICARE