Provider Demographics
NPI:1013565092
Name:MOORE-MITCHELL, DESIREA
Entity Type:Individual
Prefix:
First Name:DESIREA
Middle Name:
Last Name:MOORE-MITCHELL
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 1:5215 SPANISH DOLLAR CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-3268
Mailing Address - Country:US
Mailing Address - Phone:703-244-6847
Mailing Address - Fax:
Practice Address - Street 1:14715 BRISTOW RD
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20112-3945
Practice Address - Country:US
Practice Address - Phone:703-791-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007861235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist