Provider Demographics
NPI:1326462383
Name:MOORE, DIANE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5185 E 117TH AVE
Mailing Address - Street 2:THORNTON
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80233-1841
Mailing Address - Country:US
Mailing Address - Phone:303-596-4620
Mailing Address - Fax:
Practice Address - Street 1:8585 W DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226-3022
Practice Address - Country:US
Practice Address - Phone:303-988-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist