Provider Demographics
NPI:1700587227
Name:MOODY, CARLY ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:MOODY
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 AMBERLEIGH DR APT 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-9845
Mailing Address - Country:US
Mailing Address - Phone:970-821-5700
Mailing Address - Fax:
Practice Address - Street 1:121 AMBERLEIGH DR APT 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9845
Practice Address - Country:US
Practice Address - Phone:970-821-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001996106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty