Provider Demographics
NPI:1710649116
Name:MOODY, KRISTY LYNN
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
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 1:284 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44504-1752
Mailing Address - Country:US
Mailing Address - Phone:330-743-5309
Mailing Address - Fax:330-743-2756
Practice Address - Street 1:284 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1752
Practice Address - Country:US
Practice Address - Phone:330-743-5309
Practice Address - Fax:330-743-2756
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS2102100-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker