Provider Demographics
NPI:1659939072
Name:HARRIS-MOORE, STEPHANIE G
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:G
Last Name:HARRIS-MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1222
Mailing Address - Country:US
Mailing Address - Phone:708-408-0861
Mailing Address - Fax:
Practice Address - Street 1:228 KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1222
Practice Address - Country:US
Practice Address - Phone:708-408-0861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1874259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1874259Medicaid