Provider Demographics
NPI:1568642759
Name:MOODY, GINA KAY (PT)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:KAY
Last Name:MOODY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-1835
Mailing Address - Country:US
Mailing Address - Phone:419-302-7561
Mailing Address - Fax:
Practice Address - Street 1:510 W 1ST ST
Practice Address - Street 2:
Practice Address - City:DELPHOS
Practice Address - State:OH
Practice Address - Zip Code:45833-1835
Practice Address - Country:US
Practice Address - Phone:419-302-7561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT011946225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist