Provider Demographics
NPI:1588174304
Name:TRACEE MOSS
Entity type:Organization
Organization Name:TRACEE MOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-953-1202
Mailing Address - Street 1:3050 SOUTHWIND TRL
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-2880
Mailing Address - Country:US
Mailing Address - Phone:330-953-1202
Mailing Address - Fax:330-953-1204
Practice Address - Street 1:3050 SOUTHWIND TRL
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-2880
Practice Address - Country:US
Practice Address - Phone:330-953-1202
Practice Address - Fax:330-953-1204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0004017-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty