Provider Demographics
NPI:1083378343
Name:MOODY, MINCI SEKOU (DR)
Entity Type:Individual
Prefix:
First Name:MINCI
Middle Name:SEKOU
Last Name:MOODY
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:MINCI
Other - Middle Name:SEKOU
Other - Last Name:STENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8484 WILSHIRE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3235
Mailing Address - Country:US
Mailing Address - Phone:310-360-7690
Mailing Address - Fax:
Practice Address - Street 1:8484 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3235
Practice Address - Country:US
Practice Address - Phone:310-360-7690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-23
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA713445163WX0003X
CA95020547363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WX0003XNursing Service ProvidersRegistered NurseObstetric, Inpatient