Provider Demographics
NPI:1326469156
Name:MOORE, AMY
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:
Last Name:MOORE
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 1:59 HOOPER ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3803
Mailing Address - Country:US
Mailing Address - Phone:631-476-0407
Mailing Address - Fax:
Practice Address - Street 1:8 43RD ST
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-2325
Practice Address - Country:US
Practice Address - Phone:631-285-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58 014614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist