Provider Demographics
NPI:1578905469
Name:MOODY, DERECK
Entity Type:Individual
Prefix:MR
First Name:DERECK
Middle Name:
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 HICKMAN RD APT 3
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1209
Mailing Address - Country:US
Mailing Address - Phone:904-781-0600
Mailing Address - Fax:904-781-0016
Practice Address - Street 1:1218 HICKMAN RD APT 3
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1209
Practice Address - Country:US
Practice Address - Phone:904-781-0600
Practice Address - Fax:904-781-0016
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health