Provider Demographics
NPI:1720568876
Name:MOSS, SANDRA DELORIS
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:DELORIS
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 1:3747 HWY 57 S
Mailing Address - Street 2:
Mailing Address - City:SENATOBIA
Mailing Address - State:MS
Mailing Address - Zip Code:38668
Mailing Address - Country:US
Mailing Address - Phone:662-612-4549
Mailing Address - Fax:662-301-8596
Practice Address - Street 1:3747 HWY 57 S
Practice Address - Street 2:
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668
Practice Address - Country:US
Practice Address - Phone:662-612-4549
Practice Address - Fax:662-301-8596
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor