Provider Demographics
NPI:1174631147
Name:MOSER, BRAD B (MA, LMHC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:B
Last Name:MOSER
Suffix:
Gender:M
Credentials:MA, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 S FLORIDA AVE
Mailing Address - Street 2:SUITE 35
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3327
Mailing Address - Country:US
Mailing Address - Phone:863-644-8241
Mailing Address - Fax:863-644-9025
Practice Address - Street 1:6700 S FLORIDA AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3327
Practice Address - Country:US
Practice Address - Phone:863-644-8241
Practice Address - Fax:863-644-9025
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7813101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ064ROtherBLUECROSS BLUESHIELD