Basic Information
| Provider Information | |||||||||
| NPI: | 1851848527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOSLEY | ||||||||
| FirstName: | BRENDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5628 E SLAUSON AVE | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900402922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235998191 | ||||||||
| FaxNumber: | 3237803211 | ||||||||
| Practice Location | |||||||||
| Address1: | 43520 DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935354089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612664783 | ||||||||
| FaxNumber: | 6612661210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2016 | ||||||||
| LastUpdateDate: | 11/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 106H00000X | 121710 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | #95-2633765 | 01 | CA | MEDI-CAL | OTHER |