Provider Demographics
NPI:1154004869
Name:MOODY, LOGAN
Entity type:Individual
Prefix:
First Name:LOGAN
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 1:361 3RD ST STE B
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3580
Mailing Address - Country:US
Mailing Address - Phone:415-572-0813
Mailing Address - Fax:
Practice Address - Street 1:361 3RD ST STE B
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3580
Practice Address - Country:US
Practice Address - Phone:415-572-0813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31043101200000X
CA384134106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty