Provider Demographics
NPI:1164197364
Name:MOFFETT, COURTNEY LYNN
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 BELLERIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-2134
Mailing Address - Country:US
Mailing Address - Phone:636-751-8650
Mailing Address - Fax:
Practice Address - Street 1:4200 N CLOVERLEAF DR STE J
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-6436
Practice Address - Country:US
Practice Address - Phone:636-922-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021019478235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist