Provider Demographics
NPI:1396308912
Name:MOODY, MATTHEW DALE
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DALE
Last Name:MOODY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 BROOK ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-3457
Mailing Address - Country:US
Mailing Address - Phone:817-798-5831
Mailing Address - Fax:
Practice Address - Street 1:9 HANOVER ST STE 2
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766-1312
Practice Address - Country:US
Practice Address - Phone:603-448-0126
Practice Address - Fax:603-448-6001
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
TX106S00000X
TX2512019175T00000X
VT171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist