Provider Demographics
NPI:1104096007
Name:TROUTT-MOSS, JOHNNIE MAY
Entity type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:MAY
Last Name:TROUTT-MOSS
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 1:3207 N 7TH PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8212
Mailing Address - Country:US
Mailing Address - Phone:918-557-0386
Mailing Address - Fax:
Practice Address - Street 1:3207 N 7TH PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8212
Practice Address - Country:US
Practice Address - Phone:918-557-0386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional