Provider Demographics
NPI:1770606550
Name:MOODY, MICHELLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6002 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-5060
Mailing Address - Country:US
Mailing Address - Phone:850-957-3600
Mailing Address - Fax:850-957-9000
Practice Address - Street 1:12364 ENVIRONMENT CENTER RD
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:FL
Practice Address - Zip Code:32564
Practice Address - Country:US
Practice Address - Phone:850-957-3600
Practice Address - Fax:850-957-9000
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW85981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical