Provider Demographics
NPI:1104431386
Name:MOODY, ANNALEE ROSE
Entity type:Individual
Prefix:
First Name:ANNALEE
Middle Name:ROSE
Last Name:MOODY
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 1:801 10TH AVENUE PL
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-1778
Mailing Address - Country:US
Mailing Address - Phone:309-737-3550
Mailing Address - Fax:
Practice Address - Street 1:523 1/2 COURT STREET
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:IA
Practice Address - Zip Code:52361-5236
Practice Address - Country:US
Practice Address - Phone:319-668-1217
Practice Address - Fax:319-668-1220
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA097640101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health