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General NPI Number Information
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NPI Number | 1326837931
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Entity Type | Individual
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Provider Name | BLAKE CARENTON MOSS
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Gender | Male
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Dates
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Enumeration Date | 05/01/2025
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Last Update Date | 05/01/2025
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Provider Practice Location Address
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Address Line | 4425 ISSAQUAH PINE LAKE RD SE APT I14
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City | SAMMAMISH
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State | WA
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Zip | 98075-6247
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Country | US
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Telephone | 832-943-7204
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Fax |
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Provider Business Mailing Address
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Address Line | 33010 SE 99TH ST
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City | SNOQUALMIE
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State | WA
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Zip | 98065-9797
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Country | US
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Telephone | 425-831-2500
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CO61411437
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License Number State | WA
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