Provider Demographics
NPI:1558601674
Name:MOODY, DERICK WILLIAMS (LMP)
Entity Type:Individual
Prefix:
First Name:DERICK
Middle Name:WILLIAMS
Last Name:MOODY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4040 ORCHARD ST W
Mailing Address - Street 2:STE. 100
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6606
Mailing Address - Country:US
Mailing Address - Phone:253-564-1560
Mailing Address - Fax:253-564-4449
Practice Address - Street 1:4060 WHEATON WAY
Practice Address - Street 2:STE. C
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-3500
Practice Address - Country:US
Practice Address - Phone:360-479-8477
Practice Address - Fax:360-479-8417
Is Sole Proprietor?:No
Enumeration Date:2013-02-27
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160045527225200000X
WAMA60298052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant