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General NPI Number Information
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NPI Number | 1407738735
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Entity Type | Individual
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Provider Name | ELIJAH MOSS LPC CANDIDATE
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Gender | Male
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Dates
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Enumeration Date | 07/25/2025
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Last Update Date | 07/25/2025
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Provider Practice Location Address
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Address Line | 4845 S SHERIDAN RD STE 509
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City | TULSA
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State | OK
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Zip | 74145-5719
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Country | US
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Telephone | 405-208-4469
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Fax |
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Provider Business Mailing Address
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Address Line | 1502 N 81ST ST
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City | BROKEN ARROW
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State | OK
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Zip | 74014-7453
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Country | US
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Telephone | 918-863-6335
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LPCCANDIDATE12861
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License Number State | OK
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