Provider Demographics
NPI:1760136154
Name:MOODY, RYAN KENT
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:KENT
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 HEBRON PKWY STE 1102
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-5146
Mailing Address - Country:US
Mailing Address - Phone:972-878-8527
Mailing Address - Fax:
Practice Address - Street 1:860 HEBRON PKWY STE 1102
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-5146
Practice Address - Country:US
Practice Address - Phone:972-878-8527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX87781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health