Provider Demographics
NPI:1417239864
Name:MOSS, JUDITH K
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:K
Last Name:MOSS
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 1:2035 ALTA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-7017
Mailing Address - Country:US
Mailing Address - Phone:760-724-7898
Mailing Address - Fax:760-414-9127
Practice Address - Street 1:2035 ALTA VISTA DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-7017
Practice Address - Country:US
Practice Address - Phone:760-724-7898
Practice Address - Fax:760-414-9127
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374601463320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness