Provider Demographics
NPI:1659004364
Name:MOSS, SARA E
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:E
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 1:773 CENTER BLVD
Mailing Address - Street 2:PO BOX 653
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94978
Mailing Address - Country:US
Mailing Address - Phone:323-919-1551
Mailing Address - Fax:
Practice Address - Street 1:166 SANTA CLARA AVE STE 205
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94610-1323
Practice Address - Country:US
Practice Address - Phone:510-601-1929
Practice Address - Fax:510-660-1194
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-08
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141374106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist