Provider Demographics
NPI:1366657090
Name:MOORE, MARY LLOYD (SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:MARY LLOYD
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 1:1641 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-3501
Mailing Address - Country:US
Mailing Address - Phone:270-781-1719
Mailing Address - Fax:270-745-4233
Practice Address - Street 1:1641 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-3501
Practice Address - Country:US
Practice Address - Phone:270-781-1719
Practice Address - Fax:270-745-4233
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1498235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist