Provider Demographics
NPI:1972100105
Name:MOSS, ARSENIO (LSSP, NCSP)
Entity type:Individual
Prefix:
First Name:ARSENIO
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:LSSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX F-43708
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:GRAND BAHAMA
Mailing Address - Zip Code:00000
Mailing Address - Country:BS
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 ZACHARY LANE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:GRAND BAHAMA
Practice Address - Zip Code:00000
Practice Address - Country:BS
Practice Address - Phone:559-667-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX71511103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool