Provider Demographics
NPI:1861825887
Name:MOSES, OLIVIA C (BHA TRAINEE)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:C
Last Name:MOSES
Suffix:
Gender:F
Credentials:BHA TRAINEE
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:HORN-MOSES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:EMMONAK
Mailing Address - State:AK
Mailing Address - Zip Code:99581-0246
Mailing Address - Country:US
Mailing Address - Phone:907-949-3524
Mailing Address - Fax:
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6100
Practice Address - Fax:907-543-6159
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid