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General NPI Number Information
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NPI Number | 1053190983
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Entity Type | Individual
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Provider Name | MARY MOODY
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Gender | Female
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Dates
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Enumeration Date | 09/28/2023
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Last Update Date | 09/28/2023
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Provider Practice Location Address
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Address Line | 3840 COLONIAL DR
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City | COLUMBUS
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State | IN
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Zip | 47203-2645
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Country | US
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Telephone | 727-485-3219
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Fax |
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Provider Business Mailing Address
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Address Line | 21568 E COUNTY ROAD 400 S
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City | WESTPORT
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State | IN
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Zip | 47283-9400
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Country | US
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Telephone | 812-390-1335
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number | CNA0903587
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License Number State | IN
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