Provider Demographics
NPI:1831512938
Name:MOSLEY, ANQUINETTE LERICE (MALLP)
Entity type:Individual
Prefix:MRS
First Name:ANQUINETTE
Middle Name:LERICE
Last Name:MOSLEY
Suffix:
Gender:F
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 CONNER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3448
Mailing Address - Country:US
Mailing Address - Phone:313-308-0255
Mailing Address - Fax:313-308-0270
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-308-0255
Practice Address - Fax:313-308-0270
Is Sole Proprietor?:No
Enumeration Date:2014-01-24
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-02311101YA0400X
MI6301012034103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling