Provider Demographics
NPI:1477723831
Name:MOORE, MICHELE LYNN (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 BROOKLYN AVE
Mailing Address - Street 2:APT 1D
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2849
Mailing Address - Country:US
Mailing Address - Phone:718-735-9816
Mailing Address - Fax:718-735-9816
Practice Address - Street 1:823 BROOKLYN AVE
Practice Address - Street 2:APT 1D
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2849
Practice Address - Country:US
Practice Address - Phone:718-735-9816
Practice Address - Fax:718-735-9816
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-01
Last Update Date:2008-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011776-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist