Healthcare Provider Details

I. General information

NPI: 1134730880
Provider Name (Legal Business Name): LAUREN E MOSS SW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1759 BROAD PARK CIR S STE 113
MANSFIELD TX
76063-7836
US

IV. Provider business mailing address

1759 BROAD PARK CIR S STE 113
MANSFIELD TX
76063-7836
US

V. Phone/Fax

Practice location:
  • Phone: 817-473-1312
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: