Provider Demographics
NPI:1093586620
Name:MOSS, EDEN G (STUDENT CLINICIAN)
Entity Type:Individual
Prefix:
First Name:EDEN
Middle Name:G
Last Name:MOSS
Suffix:
Gender:F
Credentials:STUDENT CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2172 S TRENTON WAY APT 8-303
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-5386
Mailing Address - Country:US
Mailing Address - Phone:312-973-9423
Mailing Address - Fax:
Practice Address - Street 1:2450 S VINE ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5264
Practice Address - Country:US
Practice Address - Phone:303-871-3626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent