Provider Demographics
NPI:1316292717
Name:MOSS, MILTON LEE JR (MA)
Entity type:Individual
Prefix:MR
First Name:MILTON
Middle Name:LEE
Last Name:MOSS
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:MR
Other - First Name:MILTON
Other - Middle Name:LEE
Other - Last Name:MOSS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA
Mailing Address - Street 1:11733 CARROLLWOOD COVE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-4534
Mailing Address - Country:US
Mailing Address - Phone:813-417-4397
Mailing Address - Fax:866-457-5422
Practice Address - Street 1:6811 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-5500
Practice Address - Country:US
Practice Address - Phone:813-417-4397
Practice Address - Fax:866-457-5422
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-21
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9891101YM0800X
GALPC007596101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional