Provider Demographics
NPI:1306301981
Name:MOSS, JOANNA LORENE (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:LORENE
Last Name:MOSS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1489 FOUR SEASONS DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-3521
Mailing Address - Country:US
Mailing Address - Phone:541-315-6045
Mailing Address - Fax:
Practice Address - Street 1:913 NW GARDEN VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6523
Practice Address - Country:US
Practice Address - Phone:541-440-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical