Provider Demographics
NPI:1437366762
Name:MOSESON, GARY B (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:B
Last Name:MOSESON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 ODANA COURT
Mailing Address - Street 2:LUTHERAN SOCIAL SERVICES CLINIC
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719
Mailing Address - Country:US
Mailing Address - Phone:608-277-0610
Mailing Address - Fax:608-270-6651
Practice Address - Street 1:5 ODANA CT
Practice Address - Street 2:LUTHERAN SOCIAL SERVICES CLINIC
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1120
Practice Address - Country:US
Practice Address - Phone:608-277-0610
Practice Address - Fax:608-270-6651
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2737-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42106400Medicaid