Provider Demographics
NPI:1831729763
Name:MOSSA, SARAH ANNE
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:ANNE
Last Name:MOSSA
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 1:1711 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62269-2918
Mailing Address - Country:US
Mailing Address - Phone:618-589-3799
Mailing Address - Fax:618-589-3799
Practice Address - Street 1:1711 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2918
Practice Address - Country:US
Practice Address - Phone:618-589-3799
Practice Address - Fax:618-589-3799
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008000925101Y00000X
IL178005110101Y00000X
IL180011720101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14590295OtherCAQH PROVIDER ID