Provider Demographics
NPI:1366193575
Name:MOSS, EMMALEE GRACE
Entity type:Individual
Prefix:
First Name:EMMALEE
Middle Name:GRACE
Last Name:MOSS
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 1:662 ENCINITAS BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6789
Mailing Address - Country:US
Mailing Address - Phone:760-634-1125
Mailing Address - Fax:
Practice Address - Street 1:7431 MAGNOLIA AVE APT 223
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3854
Practice Address - Country:US
Practice Address - Phone:951-233-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY8150478106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician