Provider Demographics
NPI:1619566767
Name:MOSS, TANEISHA CHERRELLE (MS, LPC, NCC)
Entity Type:Individual
Prefix:MS
First Name:TANEISHA
Middle Name:CHERRELLE
Last Name:MOSS
Suffix:
Gender:F
Credentials:MS, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 OAKTOWN PL
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-3823
Mailing Address - Country:US
Mailing Address - Phone:770-712-8907
Mailing Address - Fax:
Practice Address - Street 1:6764 BLANTYRE BLVD
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-5482
Practice Address - Country:US
Practice Address - Phone:770-712-8907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012145101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional