Provider Demographics
NPI:1871217612
Name:MOSS, CHANNING ALTON (MA)
Entity type:Individual
Prefix:
First Name:CHANNING
Middle Name:ALTON
Last Name:MOSS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 SPOTSWOOD AVE APT B3
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1736
Mailing Address - Country:US
Mailing Address - Phone:804-238-7421
Mailing Address - Fax:
Practice Address - Street 1:6330 NEWTOWN RD STE 625
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4808
Practice Address - Country:US
Practice Address - Phone:757-206-2378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA101Y00000X, 101YP2500X
VA0704015307101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional