Basic Information
| Provider Information | |||||||||
| NPI: | 1558389718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | ELISABETH | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | MS CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6423 DARTMOUTH RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322172483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042307761 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 NATURE WALK PKWY | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ST. AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042307761 | ||||||||
| FaxNumber: | 9042307763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 235Z00000X | SA5418 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.