Provider Demographics
NPI:1457561177
Name:MOSSABAND, DAVID (MA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:MOSSABAND
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94573-0154
Mailing Address - Country:US
Mailing Address - Phone:310-625-9796
Mailing Address - Fax:
Practice Address - Street 1:3650 STANDISH AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407
Practice Address - Country:US
Practice Address - Phone:707-585-6108
Practice Address - Fax:707-585-6155
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78895106H00000X
CAIMF#78895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist