Provider Demographics
NPI:1225664600
Name:MOSES, SHELLY-ANN MICHELLE
Entity Type:Individual
Prefix:
First Name:SHELLY-ANN
Middle Name:MICHELLE
Last Name:MOSES
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 1:1175 GREEN ST SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-5407
Mailing Address - Country:US
Mailing Address - Phone:770-929-1470
Mailing Address - Fax:770-929-1425
Practice Address - Street 1:1175 GREEN ST SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-5407
Practice Address - Country:US
Practice Address - Phone:770-929-1470
Practice Address - Fax:770-929-1425
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1144528787Medicaid