Healthcare Provider Details

I. General information

NPI: 1699076521
Provider Name (Legal Business Name): ELIZABETH MICHELLE MOODY ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44110 ASHBURN SHOPPING PLAZA STE. 251
ASHBURN VA
20147
US

IV. Provider business mailing address

3074 S GLEBE RD.
ARLINGTON VA
22206
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-2999
  • Fax: 703-723-4144
Mailing address:
  • Phone: 703-723-2999
  • Fax: 703-723-4144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0803000234
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: