Provider Demographics
NPI:1871260471
Name:MOODY-WHITLEY, TAJAH
Entity Type:Individual
Prefix:
First Name:TAJAH
Middle Name:
Last Name:MOODY-WHITLEY
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 1:117 WHEATLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-1831
Mailing Address - Country:US
Mailing Address - Phone:857-212-0650
Mailing Address - Fax:
Practice Address - Street 1:155 MAIN DUNSTABLE RD STE 200
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3640
Practice Address - Country:US
Practice Address - Phone:857-212-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician