Provider Demographics
NPI:1134465875
Name:MOODY, HANNAH (ATC, LAT)
Entity type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:MOODY
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6941 DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-9705
Mailing Address - Country:US
Mailing Address - Phone:630-479-3751
Mailing Address - Fax:
Practice Address - Street 1:604 N 16TH ST
Practice Address - Street 2:CRAMER HALL, ROOM 215
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2117
Practice Address - Country:US
Practice Address - Phone:414-288-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-28
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0031982255A2300X
WI1792-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer