MEDICARE: BRENT ERIC MOOS MSW

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	P002840	NC

General Provider Information

NPI Number	:	1639165780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT ERIC MOOS MSW

Provider Business Mailing Address
First Line	:	3 TIMBERCREEK CT
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27712-9530
Country	:	US
Telephone Number	:	919-477-8288
Fax Number	:

Provider Business Practice Location Address
First Line	:	110 CONNER DR STE 4
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27514-7044
Country	:	US
Telephone Number	:	919-929-2311
Fax Number	:

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

Provider Enumeration Date	:	09/23/2005
Last Update Date	:	07/08/2007

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