Provider Demographics
NPI:1215462569
Name:MOEDE-LINDSEY, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:MOEDE-LINDSEY
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 1:3887 FAIRFAX RIDGE RD
Mailing Address - Street 2:APT 214
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-7502
Mailing Address - Country:US
Mailing Address - Phone:818-451-8830
Mailing Address - Fax:
Practice Address - Street 1:11200 WAPLES MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7475
Practice Address - Country:US
Practice Address - Phone:703-237-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician