Provider Demographics
NPI:1548578057
Name:MOODY, SANDRA D (MS/SLP/CCC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:D
Last Name:MOODY
Suffix:
Gender:F
Credentials:MS/SLP/CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 WATERCOLOR WAY
Mailing Address - Street 2:SUITE 103 BOX 324
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459-7350
Mailing Address - Country:US
Mailing Address - Phone:850-323-1178
Mailing Address - Fax:
Practice Address - Street 1:174 WATERCOLOR WAY
Practice Address - Street 2:SUITE 103 BOX 324
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7350
Practice Address - Country:US
Practice Address - Phone:850-323-1178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-17
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 2173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00804625AMedicaid
FLSA 2173OtherFLORIDA LICENSE SLP