Provider Demographics
NPI:1831154186
Name:MOSS, GREGORY G (LCSW)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:G
Last Name:MOSS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 N MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-2127
Mailing Address - Country:US
Mailing Address - Phone:607-545-4532
Mailing Address - Fax:
Practice Address - Street 1:84 N MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2127
Practice Address - Country:US
Practice Address - Phone:607-545-4532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR021387-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00021387Medicaid
NYIA0957Medicare ID - Type Unspecified
NY00021387Medicaid