Provider Demographics
NPI:1659617900
Name:HETLAGE, MOIRA JEAN (MS SLP)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:JEAN
Last Name:HETLAGE
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1515 24TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-3008
Practice Address - Country:US
Practice Address - Phone:425-456-5160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-13
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist