Provider Demographics
NPI:1124235833
Name:MOSS, BLEEMA (MFT)
Entity type:Individual
Prefix:MS
First Name:BLEEMA
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13419 BARBADOS WAY
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3551 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4815
Practice Address - Country:US
Practice Address - Phone:619-296-9401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMA 18478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist