Provider Demographics
NPI:1407401680
Name:MOSELEY-FANTROY, TNIYAH
Entity Type:Individual
Prefix:
First Name:TNIYAH
Middle Name:
Last Name:MOSELEY-FANTROY
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 1:2785 SOM CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-6501
Mailing Address - Country:US
Mailing Address - Phone:216-278-0288
Mailing Address - Fax:
Practice Address - Street 1:2785 SOM CENTER RD
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-6501
Practice Address - Country:US
Practice Address - Phone:216-278-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician