Provider Demographics
NPI:1790112985
Name:MOSS, EMMIE GRACE (LMT)
Entity Type:Individual
Prefix:
First Name:EMMIE
Middle Name:GRACE
Last Name:MOSS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-1500
Mailing Address - Country:US
Mailing Address - Phone:608-741-6799
Mailing Address - Fax:608-741-3808
Practice Address - Street 1:1010 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-1500
Practice Address - Country:US
Practice Address - Phone:608-741-6799
Practice Address - Fax:608-741-3808
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10006-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist