Provider Demographics
NPI:1619762358
Name:MOULTON, DANIELLE
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:MOULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 PROSE CIR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-1380
Mailing Address - Country:US
Mailing Address - Phone:678-697-8139
Mailing Address - Fax:
Practice Address - Street 1:2307 PROSE CIR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-1380
Practice Address - Country:US
Practice Address - Phone:678-697-8139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X, 251E00000X
103TH0100X, 251E00000X, 251J00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No251J00000XAgenciesNursing Care
No374U00000XNursing Service Related ProvidersHome Health Aide