Provider Demographics
NPI:1558087031
Name:MOSS, MICHAELA PATRICE
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:PATRICE
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 1:139 ALFRED DR STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-4733
Mailing Address - Country:US
Mailing Address - Phone:931-614-1916
Mailing Address - Fax:
Practice Address - Street 1:130 ALFREDO DR STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-2750
Practice Address - Country:US
Practice Address - Phone:931-548-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician