=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609088301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALLY K. MOSELEY, LPC, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 06/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 W LOOP 281 SUITE 207
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75604-2568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-297-4592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 W LOOP 281 SUITE 207
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75604-2568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-297-4592
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SALLY K MOSELEY
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 903-297-4592
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 14242
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------