Provider Demographics
NPI:1265707038
Name:MOULTON, LUCAS JAMES (LCSW, CRC, LVRC)
Entity type:Individual
Prefix:MR
First Name:LUCAS
Middle Name:JAMES
Last Name:MOULTON
Suffix:
Gender:M
Credentials:LCSW, CRC, LVRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 PROVO SLOUGH ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058
Mailing Address - Country:US
Mailing Address - Phone:801-373-1197
Mailing Address - Fax:
Practice Address - Street 1:1358 PROVO SLOUGH ACCESS RD
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058
Practice Address - Country:US
Practice Address - Phone:801-373-1197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7126504-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical