MEDICARE: MISSY MOSS, LCSW

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	7133656-3501	UT

General Provider Information

NPI Number	:	1659878361
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSY MOSS, LCSW

Provider Business Mailing Address
First Line	:	965 S MAIN ST STE 5
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-4309
Country	:	US
Telephone Number	:	435-760-0753
Fax Number	:

Provider Business Practice Location Address
First Line	:	965 S MAIN ST STE 5
Second Line	:
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-4309
Country	:	US
Telephone Number	:	435-760-0753
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH COUNSELOR
Name	:	MS. MELISSA MAE MOSS
Credential	:	LCSW
Telephone Number	:	435-760-0753

Provider Enumeration Date	:	04/09/2018
Last Update Date	:	04/09/2018

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