Healthcare Provider Details

I. General information

NPI: 1699010744
Provider Name (Legal Business Name): TODD S MOODY MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 11/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DEPAUL DR.
BRIDGETON MO
63044-0000
US

IV. Provider business mailing address

12303 DEPAUL DR.
BRIDGETON MO
63044-0000
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone: 314-577-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: