MEDICARE: MAXIE MOSES

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1356824692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAXIE MOSES

Provider Business Mailing Address
First Line	:	1414 MAIN ST
Second Line	:
City	:	MELROSE PARK
State	:	IL
Zip	:	60160-3902
Country	:	US
Telephone Number	:	708-681-4357
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 S AUSTIN BLVD
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60304-2335
Country	:	US
Telephone Number	:	312-731-3867
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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Directions to “ MAXIE MOSES ” Practice Location

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