Provider Demographics
NPI:1770778763
Name:MOSELEY, LORIN BONHAM
Entity type:Individual
Prefix:MISS
First Name:LORIN
Middle Name:BONHAM
Last Name:MOSELEY
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 1:5401 FALLOWATER LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0948
Mailing Address - Country:US
Mailing Address - Phone:540-989-1383
Mailing Address - Fax:540-989-8092
Practice Address - Street 1:5401 FALLOWATER LN
Practice Address - Street 2:SUITE C
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-0948
Practice Address - Country:US
Practice Address - Phone:540-989-1383
Practice Address - Fax:540-989-8092
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701004253101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701004253OtherANTHEM