Provider Demographics
NPI:1386685121
Name:MOORE, STACY M
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:M
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:PO BOX 406153
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-1876
Mailing Address - Country:US
Mailing Address - Phone:800-528-3277
Mailing Address - Fax:888-888-0009
Practice Address - Street 1:4369 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1279
Practice Address - Country:US
Practice Address - Phone:810-733-1385
Practice Address - Fax:810-733-7893
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI12046396237600000X
MI3501003257237600000X
MI1601000313237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386685121Medicaid
MI1386685121Medicaid