Provider Demographics
NPI:1710074299
Name:MOSS-LEWIS, MYTOIA (PROGRAM DIRECTOR)
Entity Type:Individual
Prefix:MRS
First Name:MYTOIA
Middle Name:
Last Name:MOSS-LEWIS
Suffix:
Gender:F
Credentials:PROGRAM DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13206 INDIGO CREEK LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-2548
Mailing Address - Country:US
Mailing Address - Phone:713-436-7612
Mailing Address - Fax:713-436-7610
Practice Address - Street 1:13206 INDIGO CREEK LN
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-2548
Practice Address - Country:US
Practice Address - Phone:713-436-7612
Practice Address - Fax:713-436-7610
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor