Healthcare Provider Details

I. General information

NPI: 1699460881
Provider Name (Legal Business Name): MILTON ODELL MOSES ALLEY III LCSWA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 ELAINE DR
CANTON NC
28716-3311
US

IV. Provider business mailing address

81 ELAINE DR
CANTON NC
28716-3311
US

V. Phone/Fax

Practice location:
  • Phone: 843-343-1300
  • Fax:
Mailing address:
  • Phone: 843-343-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP020468
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: