Provider Demographics
NPI:1982001707
Name:MOODY, ANGELA (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:12200 104TH ST
Mailing Address - Street 2:
Mailing Address - City:COAL VALLEY
Mailing Address - State:IL
Mailing Address - Zip Code:61240-9712
Mailing Address - Country:US
Mailing Address - Phone:309-799-7044
Mailing Address - Fax:309-799-7574
Practice Address - Street 1:208 18TH ST
Practice Address - Street 2:SUITE 208
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-8720
Practice Address - Country:US
Practice Address - Phone:309-799-7044
Practice Address - Fax:309-799-7574
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-005379101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health