Healthcare Provider Details

I. General information

NPI: 1164780581
Provider Name (Legal Business Name): LORRAINE K MOSS MS, CAP,
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2789 ORTIZ AVE
FORT MYERS FL
33905-7806
US

IV. Provider business mailing address

3763 EVANS AVE
FORT MYERS FL
33901-9302
US

V. Phone/Fax

Practice location:
  • Phone: 239-791-1586
  • Fax:
Mailing address:
  • Phone: 239-791-1586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5371
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: