Provider Demographics
NPI:1063627594
Name:MOSELEY, SULLIVAN (PHD)
Entity type:Individual
Prefix:DR
First Name:SULLIVAN
Middle Name:
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 KENILWORTH AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2959
Mailing Address - Country:US
Mailing Address - Phone:704-927-9202
Mailing Address - Fax:
Practice Address - Street 1:1100 KENILWORTH AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2959
Practice Address - Country:US
Practice Address - Phone:704-927-9202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4446101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional