Provider Demographics
NPI:1326892951
Name:MOSES, TERESA LYNETTE
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:LYNETTE
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 1:2403 E THAYER AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-5014
Mailing Address - Country:US
Mailing Address - Phone:701-595-5181
Mailing Address - Fax:
Practice Address - Street 1:2403 E THAYER AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-5014
Practice Address - Country:US
Practice Address - Phone:701-595-5181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-11
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDMOS-75-5475172A00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver