Healthcare Provider Details

I. General information

NPI: 1013246156
Provider Name (Legal Business Name): MELISSA MOODY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2009
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

V. Phone/Fax

Practice location:
  • Phone: 313-410-4992
  • Fax:
Mailing address:
  • Phone: 313-410-4992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6301009289
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number6361003906
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: