Provider Demographics
NPI:1013889179
Name:MOODY, MARY LEE BROWN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE BROWN
Last Name:MOODY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 WATER ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-3832
Mailing Address - Country:US
Mailing Address - Phone:512-296-0859
Mailing Address - Fax:
Practice Address - Street 1:806 WATER ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-3832
Practice Address - Country:US
Practice Address - Phone:512-296-0859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-19
Last Update Date:2025-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13036172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker