Provider Demographics
NPI:1821028234
Name:MOSELEY, MARIAN (PH D)
Entity Type:Individual
Prefix:DR
First Name:MARIAN
Middle Name:
Last Name:MOSELEY
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 MONTE SANO AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-5323
Mailing Address - Country:US
Mailing Address - Phone:706-667-6767
Mailing Address - Fax:706-667-6767
Practice Address - Street 1:1524 MONTE SANO AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-5323
Practice Address - Country:US
Practice Address - Phone:706-667-6767
Practice Address - Fax:706-667-6767
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001140103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0009Medicaid
GA00344968DMedicaid
R61690Medicare UPIN
SC0009Medicaid