Provider Demographics
NPI:1639994072
Name:MOSS, LINDA
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:HAMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1415 W LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2120
Mailing Address - Country:US
Mailing Address - Phone:414-975-6715
Mailing Address - Fax:
Practice Address - Street 1:1339 S GRANT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-5406
Practice Address - Country:US
Practice Address - Phone:414-975-6715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness