Provider Demographics
NPI:1417662065
Name:MOODY, SARA ELLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ELLEN
Last Name:MOODY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2365 LANES FERRY RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERN
Mailing Address - State:TN
Mailing Address - Zip Code:38059-5313
Mailing Address - Country:US
Mailing Address - Phone:731-676-1453
Mailing Address - Fax:
Practice Address - Street 1:1067 VENDALL RD
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1622
Practice Address - Country:US
Practice Address - Phone:731-287-7289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN83971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical