Provider Demographics
NPI:1700467685
Name:MOODY, BREDELL KEITH (LCMHCA)
Entity Type:Individual
Prefix:
First Name:BREDELL
Middle Name:KEITH
Last Name:MOODY
Suffix:
Gender:M
Credentials:LCMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10900 WORLD TRADE BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4202
Mailing Address - Country:US
Mailing Address - Phone:919-237-1337
Mailing Address - Fax:866-538-4716
Practice Address - Street 1:7850 BRIER CREEK PKWY STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-8900
Practice Address - Country:US
Practice Address - Phone:919-748-4878
Practice Address - Fax:919-748-4876
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA13082101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional