Provider Demographics
NPI:1417183146
Name:MOONEYHAM, KARI (SLP)
Entity Type:Individual
Prefix:
First Name:KARI
Middle Name:
Last Name:MOONEYHAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KARI
Other - Middle Name:
Other - Last Name:EDGCOMB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:900 MAIN ST
Mailing Address - Street 2:SUITE 450
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1005
Mailing Address - Country:US
Mailing Address - Phone:309-672-4568
Mailing Address - Fax:309-672-4569
Practice Address - Street 1:900 MAIN ST
Practice Address - Street 2:SUITE 450
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61602-1005
Practice Address - Country:US
Practice Address - Phone:309-672-4568
Practice Address - Fax:309-672-4569
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist