Provider Demographics
NPI:1902100118
Name:HOLLY BLANC MOSES, BCBA LPC PLLC
Entity Type:Organization
Organization Name:HOLLY BLANC MOSES, BCBA LPC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:BLANC
Authorized Official - Last Name:MOSES
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA LPC
Authorized Official - Phone:865-789-2730
Mailing Address - Street 1:306 N B ST
Mailing Address - Street 2:
Mailing Address - City:LENOIR CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37771-2420
Mailing Address - Country:US
Mailing Address - Phone:865-789-2730
Mailing Address - Fax:
Practice Address - Street 1:306 N B ST
Practice Address - Street 2:
Practice Address - City:LENOIR CITY
Practice Address - State:TN
Practice Address - Zip Code:37771-2420
Practice Address - Country:US
Practice Address - Phone:865-789-2730
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-03
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2568101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512959Medicaid