Provider Demographics
NPI:1922723956
Name:MOODY, RANDOLPH (BA CSAC-S)
Entity Type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:
Last Name:MOODY
Suffix:
Gender:M
Credentials:BA CSAC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 FRONT ROYAL PIKE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-7313
Mailing Address - Country:US
Mailing Address - Phone:540-546-3436
Mailing Address - Fax:
Practice Address - Street 1:290 FRONT ROYAL PIKE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-7313
Practice Address - Country:US
Practice Address - Phone:540-546-3436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)