Provider Demographics
NPI:1750089231
Name:MOSS, LAKEVINYA
Entity type:Individual
Prefix:
First Name:LAKEVINYA
Middle Name:
Last Name:MOSS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 CHEVY CHASE ST
Mailing Address - Street 2:
Mailing Address - City:GLADEWATER
Mailing Address - State:TX
Mailing Address - Zip Code:75647-4103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1017 CHEVY CHASE ST
Practice Address - Street 2:
Practice Address - City:GLADEWATER
Practice Address - State:TX
Practice Address - Zip Code:75647-4103
Practice Address - Country:US
Practice Address - Phone:469-647-8495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker