Provider Demographics
NPI:1215060538
Name:MOSS, NAN (LCPC, LPC)
Entity type:Individual
Prefix:
First Name:NAN
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:LCPC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 971
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-0971
Mailing Address - Country:US
Mailing Address - Phone:541-212-3151
Mailing Address - Fax:208-452-1232
Practice Address - Street 1:1509 N WHITLEY DR STE 11
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2260
Practice Address - Country:US
Practice Address - Phone:541-212-3151
Practice Address - Fax:208-452-1232
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC1279101YM0800X
IDLCPC-120101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health