Provider Demographics
NPI:1982217162
Name:MOODY, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14204 N 76TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4914
Mailing Address - Country:US
Mailing Address - Phone:918-206-5618
Mailing Address - Fax:
Practice Address - Street 1:14204 N 76TH EAST AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-4914
Practice Address - Country:US
Practice Address - Phone:918-206-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OK106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant