Provider Demographics
NPI:1578135315
Name:MOODY, DESTINI RENEE (MS, RD, CSSD)
Entity Type:Individual
Prefix:
First Name:DESTINI
Middle Name:RENEE
Last Name:MOODY
Suffix:
Gender:F
Credentials:MS, RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 PIEDMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-2325
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2227 PIEDMONT AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-2325
Practice Address - Country:US
Practice Address - Phone:510-642-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86057677133VN1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics