Healthcare Provider Details

I. General information

NPI: 1396308912
Provider Name (Legal Business Name): MATTHEW DALE MOODY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 08/11/2020
Certification Date: 08/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 HANOVER ST STE 2
LEBANON NH
03766-1312
US

IV. Provider business mailing address

31 BROOK ST APT 2
BARRE VT
05641-3457
US

V. Phone/Fax

Practice location:
  • Phone: 603-448-0126
  • Fax: 603-448-6001
Mailing address:
  • Phone: 817-798-5831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2512019
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: