Provider Demographics
NPI:1568911147
Name:MOORE, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 NW LAKE WHITNEY PL STE 103
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1606
Mailing Address - Country:US
Mailing Address - Phone:772-242-3187
Mailing Address - Fax:
Practice Address - Street 1:549 NW LAKE WHITNEY PL STE 103
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1606
Practice Address - Country:US
Practice Address - Phone:772-242-3187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-24
Last Update Date:2016-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 7830235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist