MEDICARE: MR. JERRY RANDOLPH MOSES LPC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	2817	NC

General Provider Information

NPI Number	:	1699731778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY RANDOLPH MOSES LPC

Provider Business Mailing Address
First Line	:	LRMC CMR 402
Second Line	:	BOX 249
City	:	LANDSTHUL
State	:	APO AE
Zip	:	09180
Country	:	DE
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	LANDSTHUL REGIONAL CENTER
Second Line	:
City	:	LANDSTHUL
State	:	APO AE
Zip	:	09180
Country	:	DE
Telephone Number	:	4868763
Fax Number	:

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

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	07/21/2022

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