Provider Demographics
NPI:1851783104
Name:MOSS, LESLIE SUE (MED)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:SUE
Last Name:MOSS
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1349 E 79TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-2864
Mailing Address - Country:US
Mailing Address - Phone:216-838-0280
Mailing Address - Fax:216-882-2025
Practice Address - Street 1:1349 E 79TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-2864
Practice Address - Country:US
Practice Address - Phone:216-838-0280
Practice Address - Fax:216-882-2025
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOHI229109103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool