Provider Demographics
NPI:1407523079
Name:MOSE, LOUTHILIA (LCSW)
Entity Type:Individual
Prefix:
First Name:LOUTHILIA
Middle Name:
Last Name:MOSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2687 E PROMENADE DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-4035
Mailing Address - Country:US
Mailing Address - Phone:801-645-3996
Mailing Address - Fax:
Practice Address - Street 1:2687 E PROMENADE DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-4035
Practice Address - Country:US
Practice Address - Phone:801-645-3996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7991152-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical