Provider Demographics
NPI:1629048483
Name:MOSS, WILLIAM A (PSYD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:MOSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 NATIONAL ST
Mailing Address - Street 2:STE 1
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-5908
Mailing Address - Country:US
Mailing Address - Phone:605-341-8647
Mailing Address - Fax:605-341-0489
Practice Address - Street 1:3601 CANYON LAKE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57702-3305
Practice Address - Country:US
Practice Address - Phone:605-341-8647
Practice Address - Fax:605-341-0489
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD416103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6551862Medicaid
SD7458Medicare ID - Type Unspecified