Provider Demographics
NPI:1245516871
Name:MOODIE, OPAL A
Entity type:Individual
Prefix:MISS
First Name:OPAL
Middle Name:A
Last Name:MOODIE
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:OPAL
Other - Middle Name:A
Other - Last Name:MOODIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:COTA
Mailing Address - Street 1:511 HEMPSTEAD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2737
Practice Address - Country:US
Practice Address - Phone:516-565-0388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator