Basic Information
| Provider Information | |||||||||
| NPI: | 1780722025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | VICKY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | SOUTH COMMUNITY BEHAVIORAL HEALTHCARE | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | 9375341579 | ||||||||
| Practice Location | |||||||||
| Address1: | 3095 KETTERING BLVD | ||||||||
| Address2: | SOUTH COMMUNITY BEHAVIORAL HEALTHCARE | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372938300 | ||||||||
| FaxNumber: | 9375341579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2007 | ||||||||
| 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 | 2084P0800X | 34006716M | OH | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 2384905 | 05 | OH | MEDICAID |