Provider Demographics
NPI:1255848628
Name:MOODIE, ANDROMEDA (LMFT)
Entity Type:Individual
Prefix:
First Name:ANDROMEDA
Middle Name:
Last Name:MOODIE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6928 NW 30TH AVE STE 6928
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1337
Mailing Address - Country:US
Mailing Address - Phone:954-594-6816
Mailing Address - Fax:
Practice Address - Street 1:6928 NW 30TH AVE STE 6928
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-1337
Practice Address - Country:US
Practice Address - Phone:954-594-6816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-06
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLMT4375106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health