Provider Demographics
NPI:1659672756
Name:MOODY, TYRA
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 DENEVE LANE
Mailing Address - Street 2:APT. #58
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:323-674-7464
Mailing Address - Fax:
Practice Address - Street 1:2500 WILSHIRE BLVD
Practice Address - Street 2:STE. #500
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4303
Practice Address - Country:US
Practice Address - Phone:213-639-2665
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-05
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner