Provider Demographics
NPI:1285208249
Name:MOODY, MICHELLE (MS, RMCHI)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:MS, RMCHI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 GLENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-3934
Mailing Address - Country:US
Mailing Address - Phone:352-573-9196
Mailing Address - Fax:
Practice Address - Street 1:7320 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33637-0916
Practice Address - Country:US
Practice Address - Phone:301-875-5680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH20085101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health