Basic Information
| Provider Information | |||||||||
| NPI: | 1700467685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOODY | ||||||||
| FirstName: | BREDELL | ||||||||
| MiddleName: | KEITH | ||||||||
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| Credential: | LCMHCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10900 WORLD TRADE BLVD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276174202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192371337 | ||||||||
| FaxNumber: | 8665384716 | ||||||||
| Practice Location | |||||||||
| Address1: | 7850 BRIER CREEK PKWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276178900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197484878 | ||||||||
| FaxNumber: | 9197484876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | A13082 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.