Provider Demographics
NPI:1760421770
Name:MOSLEY, ROBERT DWIGHT (MSW)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:DWIGHT
Last Name:MOSLEY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:924 N CONKLIN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-1712
Mailing Address - Country:US
Mailing Address - Phone:248-693-4835
Mailing Address - Fax:248-693-4835
Practice Address - Street 1:6960 ORCHARD LAKE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4515
Practice Address - Country:US
Practice Address - Phone:248-626-1500
Practice Address - Fax:248-626-1551
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2010-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0195871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP12140029Medicare ID - Type UnspecifiedINDIVIDUAL ID NUMBER