Provider Demographics
NPI:1417389354
Name:MOSS, MARQUE (LSCSW)
Entity Type:Individual
Prefix:
First Name:MARQUE
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 N HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:PRATT
Mailing Address - State:KS
Mailing Address - Zip Code:67124-1932
Mailing Address - Country:US
Mailing Address - Phone:719-349-0472
Mailing Address - Fax:
Practice Address - Street 1:149 S ANDOVER RD STE 100
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:KS
Practice Address - Zip Code:67002-7935
Practice Address - Country:US
Practice Address - Phone:719-349-0472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS10200104100000X
KS52111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker