Provider Demographics
NPI:1568725950
Name:MOORE, CAROLYN DIANE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:DIANE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1544 GREENLY ST
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-9674
Mailing Address - Country:US
Mailing Address - Phone:616-914-0648
Mailing Address - Fax:
Practice Address - Street 1:1544 GREENLY ST
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-9674
Practice Address - Country:US
Practice Address - Phone:616-914-0648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist