Provider Demographics
NPI:1770302986
Name:MOODY, KATHLEEN ROSE (PHD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:MOODY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 GOUGH ST STE 6
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-4474
Mailing Address - Country:US
Mailing Address - Phone:209-324-0346
Mailing Address - Fax:
Practice Address - Street 1:414 GOUGH ST STE 6
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-4474
Practice Address - Country:US
Practice Address - Phone:209-324-0346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist