Healthcare Provider Details

I. General information

NPI: 1750226775
Provider Name (Legal Business Name): KEVIN LONNELL MOODY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 NASSAU ST
DISTRICT HEIGHTS MD
20747-1218
US

IV. Provider business mailing address

5905 NASSAU ST
DISTRICT HEIGHTS MD
20747-1218
US

V. Phone/Fax

Practice location:
  • Phone: 227-225-7800
  • Fax:
Mailing address:
  • Phone: 227-225-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: