Provider Demographics
NPI:1952880775
Name:MOODY, MOLLIE (LCSW)
Entity type:Individual
Prefix:
First Name:MOLLIE
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 1:233 GUNN AVE
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2013
Mailing Address - Country:US
Mailing Address - Phone:540-330-3055
Mailing Address - Fax:
Practice Address - Street 1:3536 BRAMBLETON AVE STE 3
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-6500
Practice Address - Country:US
Practice Address - Phone:540-777-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040103491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical