Healthcare Provider Details

I. General information

NPI: 1154974285
Provider Name (Legal Business Name): MICHAEL ANTHONY MOSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8785 SW 165TH AVE STE 103
MIAMI FL
33193-5827
US

IV. Provider business mailing address

5641 RIVERSIDE DR APT 104
CORAL SPRINGS FL
33067-2908
US

V. Phone/Fax

Practice location:
  • Phone: 786-206-6500
  • Fax:
Mailing address:
  • Phone: 754-246-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-82611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: