Basic Information
| Provider Information | |||||||||
| NPI: | 1538200910 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOSS | ||||||||
| FirstName: | BONITA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W.,L.C.S.W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2810 MAPLE AVE.. | ||||||||
| Address2: | UNIT A | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272156108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362299457 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2260 S CHURCH ST | ||||||||
| Address2: | SUITE 506 | ||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272155390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3362230444 | ||||||||
| FaxNumber: | 3362230449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C000575 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.