Provider Demographics
NPI:1093066326
Name:MOORE, LINDA L (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 E LOREN ST
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1735
Mailing Address - Country:US
Mailing Address - Phone:417-732-2902
Mailing Address - Fax:
Practice Address - Street 1:639 W CHESTNUT EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3935
Practice Address - Country:US
Practice Address - Phone:417-523-7595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011013603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist