Provider Demographics
NPI:1184269235
Name:MOSLEY, GARY DARRYL SR (PLADC -1481NE)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:DARRYL
Last Name:MOSLEY
Suffix:SR
Gender:M
Credentials:PLADC -1481NE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 N 94TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-3948
Mailing Address - Country:US
Mailing Address - Phone:402-298-0136
Mailing Address - Fax:531-484-2781
Practice Address - Street 1:TAMARAK BUILDING SUITE 101 G
Practice Address - Street 2:3035 HARNEY STREET
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68131-3500
Practice Address - Country:US
Practice Address - Phone:531-389-8110
Practice Address - Fax:531-484-2781
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-13
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEPLADC1481101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)