Provider Demographics
NPI:1043487325
Name:MOORE, MELISSA A (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 PINE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76140-5431
Mailing Address - Country:US
Mailing Address - Phone:817-551-6353
Mailing Address - Fax:
Practice Address - Street 1:1030 E HIGHWAY 377
Practice Address - Street 2:202
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1456
Practice Address - Country:US
Practice Address - Phone:817-372-7380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17481235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158263702Medicaid
TX8T1042OtherBLUE CROSS BLUE SHIELD