Provider Demographics
NPI:1992354120
Name:MOODY, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
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 1:2708 MOODY RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-7302
Mailing Address - Country:US
Mailing Address - Phone:615-982-9232
Mailing Address - Fax:
Practice Address - Street 1:165 BELLE FOREST CIR STE A
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37221-2174
Practice Address - Country:US
Practice Address - Phone:615-852-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1302101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1302OtherSTATE OF TENNESSEE