Provider Demographics
NPI:1710232426
Name:MOORE, LAUREL (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:976 N 453RD LN
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:IL
Mailing Address - Zip Code:62360-2803
Mailing Address - Country:US
Mailing Address - Phone:575-635-8926
Mailing Address - Fax:
Practice Address - Street 1:976 N 453RD LN
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:IL
Practice Address - Zip Code:62360-2803
Practice Address - Country:US
Practice Address - Phone:575-635-8926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018005781235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist