Provider Demographics
NPI:1629229349
Name:MOSER-BURG, DIANA ALICE (PHD, LPC)
Entity Type:Individual
Prefix:DR
First Name:DIANA
Middle Name:ALICE
Last Name:MOSER-BURG
Suffix:
Gender:F
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 APPLEGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6726
Mailing Address - Country:US
Mailing Address - Phone:757-285-0565
Mailing Address - Fax:
Practice Address - Street 1:2923 S TRYON ST
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5852
Practice Address - Country:US
Practice Address - Phone:704-256-4893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6104058Medicaid