Healthcare Provider Details

I. General information

NPI: 1093543654
Provider Name (Legal Business Name): INTEGRATIVE CLINICAL PSYCHOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 WATERS EDGE DR STE 108
GRANBURY TX
76048-1474
US

IV. Provider business mailing address

5640 MESA LOOP
GRANBURY TX
76048-6554
US

V. Phone/Fax

Practice location:
  • Phone: 817-559-1754
  • Fax:
Mailing address:
  • Phone: 405-620-3508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFF A MOODY
Title or Position: OWNER
Credential: PSYD
Phone: 817-559-1754