Provider Demographics
NPI:1710999388
Name:MOODY, EMILY DIANE (MSW)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:DIANE
Last Name:MOODY
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8614 OCEAN GTWY 4
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-7217
Mailing Address - Country:US
Mailing Address - Phone:410-690-8181
Mailing Address - Fax:410-690-8185
Practice Address - Street 1:28534 GRANVILLE LN
Practice Address - Street 2:
Practice Address - City:TRAPPE
Practice Address - State:MD
Practice Address - Zip Code:21673-1879
Practice Address - Country:US
Practice Address - Phone:301-873-5148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3035651041C0700X
MD127701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC016820C67Medicare ID - Type Unspecified
DCQ41229Medicare UPIN