Basic Information
| Provider Information | |||||||||
| NPI: | 1306084769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LBSW, JP, IPR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2805 FOUNTAIN PLAZA BLVD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785398031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563162224 | ||||||||
| FaxNumber: | 9563161717 | ||||||||
| Practice Location | |||||||||
| Address1: | 2805 FOUNTAIN PLAZA BLVD | ||||||||
| Address2: | |||||||||
| City: | EDINBURG | ||||||||
| State: | TX | ||||||||
| PostalCode: | 785398031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9563162224 | ||||||||
| FaxNumber: | 9563161717 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 171M00000X | 17286 | TX | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1988032 | 05 | TX | MEDICAID |