Provider Demographics
NPI:1639869969
Name:MOORE CUSTARD LLC
Entity Type:Organization
Organization Name:MOORE CUSTARD LLC
Other - Org Name:MOORE SPEECH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:BUCKNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCC/SLP
Authorized Official - Phone:832-642-1889
Mailing Address - Street 1:2123 SILVER MOON TRL
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:TX
Mailing Address - Zip Code:77532-3503
Mailing Address - Country:US
Mailing Address - Phone:832-642-1889
Mailing Address - Fax:
Practice Address - Street 1:20111 FM 2100 RD STE 115
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:TX
Practice Address - Zip Code:77532-3730
Practice Address - Country:US
Practice Address - Phone:832-642-1889
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty