Provider Demographics
NPI:1124177217
Name:MOODY, JOY SUSANNE (COTA)
Entity type:Individual
Prefix:MS
First Name:JOY
Middle Name:SUSANNE
Last Name:MOODY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 102
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:AR
Mailing Address - Zip Code:71766-9707
Mailing Address - Country:US
Mailing Address - Phone:870-352-8420
Mailing Address - Fax:
Practice Address - Street 1:1717 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-7104
Practice Address - Country:US
Practice Address - Phone:870-352-7975
Practice Address - Fax:870-352-8806
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAT-443224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant