Provider Demographics
NPI:1134769284
Name:MOODY, KHALIAH SALEEM
Entity type:Individual
Prefix:
First Name:KHALIAH
Middle Name:SALEEM
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 1:5236 DELANCEY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19143-1506
Mailing Address - Country:US
Mailing Address - Phone:267-259-9199
Mailing Address - Fax:
Practice Address - Street 1:5236 DELANCEY ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19143-1506
Practice Address - Country:US
Practice Address - Phone:267-259-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-07
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH004078103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst