Provider Demographics
NPI:1689865628
Name:MOORE, CANDACE RENATA (CCC,SLP)
Entity Type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:RENATA
Last Name:MOORE
Suffix:
Gender:F
Credentials:CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 VICEROY CURV
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-9140
Mailing Address - Country:US
Mailing Address - Phone:504-340-4433
Mailing Address - Fax:877-578-3333
Practice Address - Street 1:312 VICEROY CURV
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-9140
Practice Address - Country:US
Practice Address - Phone:504-491-3332
Practice Address - Fax:877-578-8794
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006149235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist