Provider Demographics
NPI:1659875904
Name:MOSELEY, EZEKIEL
Entity Type:Individual
Prefix:
First Name:EZEKIEL
Middle Name:
Last Name:MOSELEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 W HOSPITALITY LN STE 201D
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3245
Mailing Address - Country:US
Mailing Address - Phone:951-708-1049
Mailing Address - Fax:
Practice Address - Street 1:225 W HOSPITALITY LN STE 201D
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3245
Practice Address - Country:US
Practice Address - Phone:951-708-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health