Provider Demographics
NPI:1801029806
Name:PORTMAN-MOORE, MEGAN M
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:PORTMAN-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 1:816 JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98844
Mailing Address - Country:US
Mailing Address - Phone:509-476-3612
Mailing Address - Fax:
Practice Address - Street 1:816 JUNIPER ST
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:WA
Practice Address - Zip Code:98844-9373
Practice Address - Country:US
Practice Address - Phone:509-476-3612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0448275235Z00000X
WA462346H235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist