Provider Demographics
NPI:1467639898
Name:MELODIE K MOOREHEAD, PHD, ABPP, PA
Entity Type:Organization
Organization Name:MELODIE K MOOREHEAD, PHD, ABPP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELODIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:MOOREHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-444-1445
Mailing Address - Street 1:1201 E BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2133
Mailing Address - Country:US
Mailing Address - Phone:954-444-1445
Mailing Address - Fax:
Practice Address - Street 1:1201 E BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2133
Practice Address - Country:US
Practice Address - Phone:954-444-1445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75811OtherBC/BS