Provider Demographics
NPI:1083824585
Name:MOODY, CHARLES B (LSW-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:B
Last Name:MOODY
Suffix:
Gender:M
Credentials:LSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 CALLAGHAN RD
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730
Mailing Address - Country:US
Mailing Address - Phone:207-532-2405
Mailing Address - Fax:
Practice Address - Street 1:2 WATER ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-2126
Practice Address - Country:US
Practice Address - Phone:207-532-5510
Practice Address - Fax:207-532-5518
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELSX7340171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME259340099Medicaid