Healthcare Provider Details

I. General information

NPI: 1629229349
Provider Name (Legal Business Name): DIANA ALICE MOSER-BURG PHD, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 S TRYON ST SUITE 220
CHARLOTTE NC
28203-5852
US

IV. Provider business mailing address

1211 APPLEGATE PKWY
WAXHAW NC
28173-6726
US

V. Phone/Fax

Practice location:
  • Phone: 704-256-4893
  • Fax:
Mailing address:
  • Phone: 757-285-0565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7203
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: