Healthcare Provider Details

I. General information

NPI: 1841636362
Provider Name (Legal Business Name): CASEY MOODY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASEY HOLT LCSW

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6440 S LEWIS AVE STE 2200
TULSA OK
74136-1060
US

IV. Provider business mailing address

1601 OLD SOUTH RIVER RD
SAINT CHARLES MO
63303-4120
US

V. Phone/Fax

Practice location:
  • Phone: 918-712-0859
  • Fax: 918-388-6456
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-246-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2021011487
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7060
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: