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General NPI Number Information
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NPI Number | 1619147394
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Entity Type | Individual
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Provider Name | JOHN MOSS CADC, CODP, QMHP
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Gender | Male
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Dates
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Enumeration Date | 03/10/2008
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Last Update Date | 08/21/2019
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Provider Practice Location Address
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Address Line | 1320 UNION ST
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City | MORRIS
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State | IL
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Zip | 60450-2426
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Country | US
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Telephone | 815-941-3142
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Fax |
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Provider Business Mailing Address
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Address Line | 1148 COUNTY ROAD 27
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City | MOUNTAIN HOME
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State | AR
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Zip | 72653-7948
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Country | US
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Telephone |
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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 | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 34538
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License Number State | IL
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