Provider Demographics
NPI:1134586654
Name:MOSS, RANDY K (PHD)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:K
Last Name:MOSS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4589 RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GREEN
Mailing Address - State:UT
Mailing Address - Zip Code:84050-5515
Mailing Address - Country:US
Mailing Address - Phone:907-232-5374
Mailing Address - Fax:801-544-3819
Practice Address - Street 1:447 N 300 W
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-4203
Practice Address - Country:US
Practice Address - Phone:907-232-5374
Practice Address - Fax:801-544-3819
Is Sole Proprietor?:No
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral