Healthcare Provider Details

I. General information

NPI: 1699731778
Provider Name (Legal Business Name): JERRY RANDOLPH MOSES LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTHUL REGIONAL CENTER
LANDSTHUL APO AE
09180
DE

IV. Provider business mailing address

LRMC CMR 402 BOX 249
LANDSTHUL APO AE
09180
DE

V. Phone/Fax

Practice location:
  • Phone: 4868763
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2817
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: