Provider Demographics
NPI:1114458528
Name:MOORE, CANDACE (SLP-CCC)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 N OAKLAND ST APT 504
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-5857
Mailing Address - Country:US
Mailing Address - Phone:252-327-2814
Mailing Address - Fax:
Practice Address - Street 1:6003 MASONDALE RD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315-5596
Practice Address - Country:US
Practice Address - Phone:304-488-4372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008172235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist