Provider Demographics
NPI:1801912852
Name:MOSS, SHELLEY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:MARIE
Last Name:MOSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223 QUEENS AVE
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95991-2413
Mailing Address - Country:US
Mailing Address - Phone:530-671-3939
Mailing Address - Fax:
Practice Address - Street 1:295 GRASS VALLEY HWY
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-4533
Practice Address - Country:US
Practice Address - Phone:530-888-8326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT6829174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist