MEDICARE: AVA BERNICE MOODY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor

General Provider Information

NPI Number	:	1043588635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVA BERNICE MOODY

Provider Business Mailing Address
First Line	:	724 E 95TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-1915
Country	:	US
Telephone Number	:	323-590-6190
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 E 95TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90002-1915
Country	:	US
Telephone Number	:	323-590-6190
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2011
Last Update Date	:	12/09/2011

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