MEDICARE: DR. ANISSA L MOODY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	TP# 093-997	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TP# 093-997	OTHER	NJ	LICENSE NUMBER

General Provider Information

NPI Number	:	1386876977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANISSA L MOODY PH.D.

Provider Business Mailing Address
First Line	:	905 HERRONTOWN RD
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08540-1901
Country	:	US
Telephone Number	:	646-546-0835
Fax Number	:

Provider Business Practice Location Address
First Line	:	703 BLUE SPRING RD
Second Line	:
City	:	PRINCETON
State	:	NJ
Zip	:	08540-1636
Country	:	US
Telephone Number	:	646-546-0835
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/14/2009
Last Update Date	:	10/07/2009

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