Provider Demographics
NPI:1417716283
Name:BODY, MYRANDA-LYNN MARIE (LCSW-A)
Entity Type:Individual
Prefix:
First Name:MYRANDA-LYNN
Middle Name:MARIE
Last Name:BODY
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 EDGEHILL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-0219
Mailing Address - Country:US
Mailing Address - Phone:910-703-9908
Mailing Address - Fax:
Practice Address - Street 1:3425 MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1608
Practice Address - Country:US
Practice Address - Phone:910-703-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0189831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical