Provider Demographics
NPI:1053881755
Name:MOODY, ELLIE D
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:D
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 WISTERIA DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30054-4040
Mailing Address - Country:US
Mailing Address - Phone:678-360-0488
Mailing Address - Fax:
Practice Address - Street 1:2300 W PARK PL STE 135
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3561
Practice Address - Country:US
Practice Address - Phone:678-330-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)