Provider Demographics
NPI:1083263891
Name:MOODY, MORRINE MARY (CCCSLP)
Entity Type:Individual
Prefix:
First Name:MORRINE
Middle Name:MARY
Last Name:MOODY
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 N LINCOLN AVE APT 219
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-5699
Mailing Address - Country:US
Mailing Address - Phone:970-310-8470
Mailing Address - Fax:
Practice Address - Street 1:1000 E STUART ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-1555
Practice Address - Country:US
Practice Address - Phone:970-482-5712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000961235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist