Provider Demographics
NPI:1649250564
Name:MOODY MEZA, PATRECE ELISABETH (LCSW)
Entity type:Individual
Prefix:MS
First Name:PATRECE
Middle Name:ELISABETH
Last Name:MOODY MEZA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PATRECE
Other - Middle Name:E
Other - Last Name:MOODY MEZA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:190 W. MAIN STREET KUNA COUNSELING CENTER
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-0959
Mailing Address - Country:US
Mailing Address - Phone:208-922-9001
Mailing Address - Fax:208-922-3778
Practice Address - Street 1:190 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-0959
Practice Address - Country:US
Practice Address - Phone:208-733-1996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW 4571041C0700X
ID4571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical