MEDICARE: CRYSTAL ELIZABETH MOODY

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	224Z00000X	Occupational Therapy Assistant	OTA14230	FL

General Provider Information

NPI Number	:	1912571159
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL ELIZABETH MOODY

Provider Business Mailing Address
First Line	:	1656 S JEFFERSON ST
Second Line	:
City	:	MONTICELLO
State	:	FL
Zip	:	32344-1652
Country	:	US
Telephone Number	:	850-997-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1656 S JEFFERSON ST
Second Line	:
City	:	MONTICELLO
State	:	FL
Zip	:	32344-1652
Country	:	US
Telephone Number	:	850-997-1800
Fax Number	:

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

Provider Enumeration Date	:	05/13/2021
Last Update Date	:	05/13/2021

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Directions to “ CRYSTAL ELIZABETH MOODY ” Practice Location

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