Provider Demographics
NPI:1598881294
Name:MOODY, SUSAN PAULINE (COTAL)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:PAULINE
Last Name:MOODY
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:PAULINE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 564
Mailing Address - Street 2:
Mailing Address - City:SOPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:25921-0564
Mailing Address - Country:US
Mailing Address - Phone:304-683-4867
Mailing Address - Fax:304-925-8018
Practice Address - Street 1:699 S PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2627
Practice Address - Country:US
Practice Address - Phone:304-925-1532
Practice Address - Fax:304-925-8018
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC1358224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant