Provider Demographics
NPI:1174740815
Name:MOSER FAMILY THERAPY
Entity type:Organization
Organization Name:MOSER FAMILY THERAPY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MOSER
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:386-752-7116
Mailing Address - Street 1:343 E DUVAL ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4088
Mailing Address - Country:US
Mailing Address - Phone:386-752-7116
Mailing Address - Fax:386-752-7188
Practice Address - Street 1:343 E DUVAL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4088
Practice Address - Country:US
Practice Address - Phone:386-752-7116
Practice Address - Fax:386-752-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW34231041C0700X
FLMT1085106H00000X
FLSW18231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ134BOtherBCBS GROUP #
FLZ2382OtherBCBS IND #
FLZ7484OtherBCBS IND #
FLK4298Medicare ID - Type UnspecifiedMEDICARE PART B