Provider Demographics
NPI:1619080421
Name:MOSSMAN, SUSAN B (MA)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
Last Name:MOSSMAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4332
Mailing Address - Country:US
Mailing Address - Phone:505-425-2707
Mailing Address - Fax:505-425-3324
Practice Address - Street 1:920 5TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4332
Practice Address - Country:US
Practice Address - Phone:505-425-2707
Practice Address - Fax:505-425-3324
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0169101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health