Provider Demographics
NPI:1033590955
Name:MOSS, WENDELL DEMARR (MA)
Entity Type:Individual
Prefix:MR
First Name:WENDELL
Middle Name:DEMARR
Last Name:MOSS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2231 RUCKER AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2783
Mailing Address - Country:US
Mailing Address - Phone:425-224-6693
Mailing Address - Fax:
Practice Address - Street 1:1622 3RD ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-5004
Practice Address - Country:US
Practice Address - Phone:425-224-6693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60473731101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health