Provider Demographics
NPI:1962869834
Name:MOSS, RANDI (SSP)
Entity type:Individual
Prefix:
First Name:RANDI
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:SSP
Other - Prefix:
Other - First Name:RANDI
Other - Middle Name:
Other - Last Name:FLANSBURG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:127 JOHNSTONE LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440-8555
Mailing Address - Country:US
Mailing Address - Phone:518-469-0758
Mailing Address - Fax:
Practice Address - Street 1:800 LEGION ST
Practice Address - Street 2:SUITE 220C
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4825
Practice Address - Country:US
Practice Address - Phone:843-468-1850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-24
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4656103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool