MEDICARE: BONNIE P MOODY LCSW

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	1041C0700X	Clinical Social Worker	LSW0000003398	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306941851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE P MOODY LCSW

Provider Business Mailing Address
First Line	:	7431 114TH AVE STE 104
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33773-5119
Country	:	US
Telephone Number	:	800-632-6074
Fax Number	:

Provider Business Practice Location Address
First Line	:	6110 SHALLOWFORD RD
Second Line	:
City	:	CHATTANOOGA
State	:	TN
Zip	:	37421-1894
Country	:	US
Telephone Number	:	800-632-6074
Fax Number	:

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	11/17/2010

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