Provider Demographics
NPI:1003212358
Name:MOSES, REGGIE (ST)
Entity Type:Individual
Prefix:
First Name:REGGIE
Middle Name:
Last Name:MOSES
Suffix:
Gender:M
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5204
Mailing Address - Country:US
Mailing Address - Phone:704-332-0081
Mailing Address - Fax:704-332-0085
Practice Address - Street 1:900 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5204
Practice Address - Country:US
Practice Address - Phone:704-332-0081
Practice Address - Fax:704-332-0085
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral