Provider Demographics
NPI:1932441961
Name:MOSES, MYRA EMILY (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:MYRA
Middle Name:EMILY
Last Name:MOSES
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 CRESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3136
Mailing Address - Country:US
Mailing Address - Phone:208-757-0721
Mailing Address - Fax:
Practice Address - Street 1:1600 JOHN ADAMS PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4300
Practice Address - Country:US
Practice Address - Phone:208-529-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-27988104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1073662052Medicaid