Provider Demographics
NPI:1104623545
Name:MOODY, SHAWN (CPSS)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:MOODY
Suffix:
Gender:
Credentials:CPSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:179 FULDER RD.
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-541-1245
Mailing Address - Fax:
Practice Address - Street 1:179 FULDER RD.
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812
Practice Address - Country:US
Practice Address - Phone:803-541-1245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist