Provider Demographics
NPI:1821429697
Name:MOSS, SAMANTHA ALEXIS (LCSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ALEXIS
Last Name:MOSS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6345 BALBOA BLVD STE 310
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-1500
Mailing Address - Country:US
Mailing Address - Phone:818-312-2100
Mailing Address - Fax:
Practice Address - Street 1:4325 W SUNSET BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2180
Practice Address - Country:US
Practice Address - Phone:310-388-7983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60353101YM0800X
CA808271041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health