Provider Demographics
NPI:1154569515
Name:MOORE, LISA KAY (MSE CCC SLP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSE CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4326
Mailing Address - Country:US
Mailing Address - Phone:501-982-2128
Mailing Address - Fax:
Practice Address - Street 1:1301 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4326
Practice Address - Country:US
Practice Address - Phone:501-982-2128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-22
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR611235500000X, 235Z00000X
ARSP611235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139362721Medicaid