Healthcare Provider Details

I. General information

NPI: 1205757580
Provider Name (Legal Business Name):
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 N 65TH ST
PHILADELPHIA PA
19151-4003
US

IV. Provider business mailing address

406 N 65TH ST
PHILADELPHIA PA
19151-4003
US

V. Phone/Fax

Practice location:
  • Phone: 215-791-8430
  • Fax: 888-493-3438
Mailing address:
  • Phone: 215-791-8430
  • Fax: 888-493-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: MISS KHALIAH MOODY
Title or Position: FOUNDER/CEO
Credential: MS, LBS, BCBA
Phone: 215-791-8430