MEDICARE: MOSER FAMILY THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	SW3423	FL
2	106H00000X	Marriage & Family Therapist	MT1085	FL
3	1041C0700X	Clinical Social Worker	SW1823	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Z134B	OTHER	FL	BCBS GROUP #
2	Z2382	OTHER	FL	BCBS IND #
3	Z7484	OTHER	FL	BCBS IND #

General Provider Information

NPI Number	:	1174740815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOSER FAMILY THERAPY

Provider Business Mailing Address
First Line	:	343 E DUVAL ST
Second Line	:	SUITE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4088
Country	:	US
Telephone Number	:	386-752-7116
Fax Number	:	386-752-7188

Provider Business Practice Location Address
First Line	:	343 E DUVAL ST
Second Line	:	SUITE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4088
Country	:	US
Telephone Number	:	386-752-7116
Fax Number	:	386-752-7188

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. JOHN MARK MOSER
Credential	:	M.S.W.
Telephone Number	:	386-752-7116

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	09/21/2007

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Directions to “MOSER FAMILY THERAPY ” Practice Location

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