Provider Demographics
NPI:1508489774
Name:MOSS, SUMMER
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:
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 1:503 32ND ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3005
Mailing Address - Country:US
Mailing Address - Phone:619-709-7003
Mailing Address - Fax:
Practice Address - Street 1:665 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94592-1177
Practice Address - Country:US
Practice Address - Phone:707-556-8921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297231225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist