Provider Demographics
NPI:1235906579
Name:MOODY-PROULX, ANIKA (MS, BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:ANIKA
Middle Name:
Last Name:MOODY-PROULX
Suffix:
Gender:F
Credentials:MS, BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13310 S RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4961
Mailing Address - Country:US
Mailing Address - Phone:704-945-8009
Mailing Address - Fax:
Practice Address - Street 1:13310 S RIDGE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-4961
Practice Address - Country:US
Practice Address - Phone:704-945-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-06
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1584103K00000X
NH103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty