Provider Demographics
NPI:1992918148
Name:MOOREHEAD, MELODIE KAY (PHD,ABPP)
Entity type:Individual
Prefix:DR
First Name:MELODIE
Middle Name:KAY
Last Name:MOOREHEAD
Suffix:
Gender:F
Credentials:PHD,ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 E BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2133
Mailing Address - Country:US
Mailing Address - Phone:954-444-1445
Mailing Address - Fax:954-779-7994
Practice Address - Street 1:1201 E BROWARD BLVD
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33301-2133
Practice Address - Country:US
Practice Address - Phone:954-444-1445
Practice Address - Fax:954-779-7994
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4324103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75811OtherBC/BS