Provider Demographics
NPI:1689826497
Name:MOBERG, DENICE J (BS, MS)
Entity Type:Individual
Prefix:
First Name:DENICE
Middle Name:J
Last Name:MOBERG
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 OAK KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-1363
Mailing Address - Country:US
Mailing Address - Phone:937-299-2062
Mailing Address - Fax:
Practice Address - Street 1:150 OAK KNOLL DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-1363
Practice Address - Country:US
Practice Address - Phone:937-299-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-13
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-0159235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist