Provider Demographics
NPI:1619147394
Name:MOSS, JOHN (CADC, CODP, QMHP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MOSS
Suffix:
Gender:M
Credentials:CADC, CODP, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 COUNTY ROAD 27
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-7948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 UNION ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-2426
Practice Address - Country:US
Practice Address - Phone:815-941-3142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
IL34538101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator