Provider Demographics
NPI:1710691639
Name:MOSS, MARLYNN AISHA
Entity Type:Individual
Prefix:
First Name:MARLYNN
Middle Name:AISHA
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7427 BALANCING ROCK CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4236
Mailing Address - Country:US
Mailing Address - Phone:704-804-8763
Mailing Address - Fax:
Practice Address - Street 1:875 RAYS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WHISPERING PINES
Practice Address - State:NC
Practice Address - Zip Code:28327-5910
Practice Address - Country:US
Practice Address - Phone:910-260-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCRBT-21-165644106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician