Provider Demographics
NPI:1306084769
Name:MOODY, CYNTHIA M (LBSW, JP, IPR)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:M
Last Name:MOODY
Suffix:
Gender:F
Credentials:LBSW, JP, IPR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 FOUNTAIN PLAZA BLVD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-8031
Mailing Address - Country:US
Mailing Address - Phone:956-316-2224
Mailing Address - Fax:956-316-1717
Practice Address - Street 1:2805 FOUNTAIN PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-8031
Practice Address - Country:US
Practice Address - Phone:956-316-2224
Practice Address - Fax:956-316-1717
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X, 1041C0700X
TX17286171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1988032Medicaid