Provider Demographics
NPI:1598092074
Name:MOODY, COLLEEN UNA (DSP CRMA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:UNA
Last Name:MOODY
Suffix:
Gender:F
Credentials:DSP CRMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 BIRMINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:ME
Mailing Address - Zip Code:04330
Mailing Address - Country:US
Mailing Address - Phone:207-582-0016
Mailing Address - Fax:207-582-0016
Practice Address - Street 1:198 BIRMINGHAM RD
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-582-0016
Practice Address - Fax:207-582-0016
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-04
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALL53665372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME209330000Medicaid