Provider Demographics
NPI:1831215292
Name:MOSS, KIM D (PSYD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:D
Last Name:MOSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5588 RHONDA RD
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-9021
Mailing Address - Country:US
Mailing Address - Phone:410-549-7360
Mailing Address - Fax:
Practice Address - Street 1:3355 SAINT JOHNS LN
Practice Address - Street 2:STE F
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2605
Practice Address - Country:US
Practice Address - Phone:410-655-1834
Practice Address - Fax:410-480-0110
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD02739103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR0900001Medicare UPIN
MDGJ80KDMedicare ID - Type Unspecified