MEDICARE: MRS. ELIZABETH MOODY OTR/L

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	225XP0200X	Pediatric Occupational Therapist	5280	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5280	OTHER	NC	NC BOARD OF OT LICENSE #
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477637411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELIZABETH MOODY OTR/L

Provider Business Mailing Address
First Line	:	5709 POPLIN RD
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-6727
Country	:	US
Telephone Number	:	704-628-6136
Fax Number	:

Provider Business Practice Location Address
First Line	:	5709 POPLIN RD
Second Line	:
City	:	INDIAN TRAIL
State	:	NC
Zip	:	28079-6727
Country	:	US
Telephone Number	:	704-628-6136
Fax Number	:

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	12/20/2010

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