Provider Demographics
NPI:1760656722
Name:MOORE, TAMARA S (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4218 W MORRIS HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1949
Mailing Address - Country:US
Mailing Address - Phone:208-284-0849
Mailing Address - Fax:
Practice Address - Street 1:4218 W MORRIS HILL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1949
Practice Address - Country:US
Practice Address - Phone:208-284-0849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-21
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1813235Z00000X
MO2008006403235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist