Provider Demographics
NPI:1780722025
Name:MOODY, VICKY L (DO)
Entity type:Individual
Prefix:DR
First Name:VICKY
Middle Name:L
Last Name:MOODY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3095 KETTERING BLVD
Mailing Address - Street 2:SOUTH COMMUNITY BEHAVIORAL HEALTHCARE
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45439
Mailing Address - Country:US
Mailing Address - Phone:937-293-8300
Mailing Address - Fax:937-534-1579
Practice Address - Street 1:3095 KETTERING BLVD
Practice Address - Street 2:SOUTH COMMUNITY BEHAVIORAL HEALTHCARE
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:937-534-1579
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006716M2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2384905Medicaid
E04929Medicare UPIN