Healthcare Provider Details

I. General information

NPI: 1750683561
Provider Name (Legal Business Name): JODY L MOSHER MA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2010
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 N 1ST ST W UPPER
MISSOULA MT
59802-3626
US

IV. Provider business mailing address

PO BOX 8028
MISSOULA MT
59807-8028
US

V. Phone/Fax

Practice location:
  • Phone: 406-529-5849
  • Fax: 406-728-5178
Mailing address:
  • Phone: 406-529-5849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1509
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: