Provider Demographics
NPI:1700250875
Name:MOODY, LORI DENISE (LPCA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:DENISE
Last Name:MOODY
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1429
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-1429
Mailing Address - Country:US
Mailing Address - Phone:502-538-1041
Mailing Address - Fax:502-538-1141
Practice Address - Street 1:400 CUNNINGHAM WAY
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-8339
Practice Address - Country:US
Practice Address - Phone:859-236-5507
Practice Address - Fax:502-538-1148
Is Sole Proprietor?:No
Enumeration Date:2015-11-30
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLPCCCA00216361101YP2500X
KY16480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional