Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) |
NPI | 1003938135 |
---|---|
Provider Name | Louis Moody |
First Address | West Covina, CA 91790-4621 |
Second Address | El Monte, CA 91731-3299 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2007 |
Last Update Date | 20/09/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
743045262 | TAX ID (01) | CA |