Provider Demographics
NPI:1528552098
Name:MOORE, ELYSE RENEE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:RENEE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12218 STAGECOACH RD
Mailing Address - Street 2:
Mailing Address - City:HICKMAN
Mailing Address - State:NE
Mailing Address - Zip Code:68372-7011
Mailing Address - Country:US
Mailing Address - Phone:402-217-5541
Mailing Address - Fax:
Practice Address - Street 1:12218 STAGECOACH RD
Practice Address - Street 2:
Practice Address - City:HICKMAN
Practice Address - State:NE
Practice Address - Zip Code:68372-7011
Practice Address - Country:US
Practice Address - Phone:402-217-5541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-19
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14049670OtherAMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION