Healthcare Provider Details

I. General information

NPI: 1649364209
Provider Name (Legal Business Name): STEPHANIE L MOODY ATC/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 FAIRVIEW PARK DRIVE
DUBLIN GA
31021
US

IV. Provider business mailing address

101 FAIRVIEW PARK DRIVE
DUBLIN GA
31021
US

V. Phone/Fax

Practice location:
  • Phone: 478-272-7494
  • Fax: 478-272-2616
Mailing address:
  • Phone: 478-272-7494
  • Fax: 478-272-2616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000957
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: