Provider Demographics
NPI:1659411882
Name:MOODY, ALICE (PSYD)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21900 WILLAMETTE DR STE 202
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-3284
Mailing Address - Country:US
Mailing Address - Phone:503-653-0631
Mailing Address - Fax:
Practice Address - Street 1:21900 WILLAMETTE DR STE 202
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-3284
Practice Address - Country:US
Practice Address - Phone:503-653-0631
Practice Address - Fax:503-653-1464
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR917103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR121461Medicare ID - Type Unspecified