Provider Demographics
NPI:1114104213
Name:MOORE, NIMA JEAN (MS CCCSLP)
Entity Type:Individual
Prefix:MS
First Name:NIMA
Middle Name:JEAN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY STATION
Mailing Address - Street 2:A1100 CMA 2200
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712
Mailing Address - Country:US
Mailing Address - Phone:512-471-3841
Mailing Address - Fax:512-232-1804
Practice Address - Street 1:2504 A WHITIS
Practice Address - Street 2:CMA 2200 A1100
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712
Practice Address - Country:US
Practice Address - Phone:512-471-3841
Practice Address - Fax:512-232-1804
Is Sole Proprietor?:No
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18213235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist