Provider Demographics
NPI:1194206003
Name:MOSELEY, FAITH MARIE ANTONETTE
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:MARIE ANTONETTE
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36835 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8212
Mailing Address - Country:US
Mailing Address - Phone:559-481-0679
Mailing Address - Fax:
Practice Address - Street 1:1915 HOWARD RD STE B&C
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5163
Practice Address - Country:US
Practice Address - Phone:559-330-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3967645106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician