Provider Demographics
NPI:1467632323
Name:MOODY, STEVEB JOHN (LPC)
Entity Type:Individual
Prefix:MR
First Name:STEVEB
Middle Name:JOHN
Last Name:MOODY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 E SUNNYSIDE RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8280
Mailing Address - Country:US
Mailing Address - Phone:208-529-5777
Mailing Address - Fax:208-529-5778
Practice Address - Street 1:2375 E SUNNYSIDE RD
Practice Address - Street 2:SUITE C
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8280
Practice Address - Country:US
Practice Address - Phone:208-529-5777
Practice Address - Fax:208-529-5778
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-3913101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional