Basic Information
| Provider Information | |||||||||
| NPI: | 1811432818 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MOSS | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
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| OtherCredential: | LPCA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 712 WILLIE BEATTY CT | ||||||||
| Address2: | |||||||||
| City: | STATESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286774872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046401818 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 284 EXECUTIVE PARK DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280251831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049391100 | ||||||||
| FaxNumber: | 7049391173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2016 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | A10872 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | A10872 | NC | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.