Provider Demographics
NPI:1801223292
Name:MOORE, NICOLE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:6927 SYLVAN WOODS DR
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-6435
Mailing Address - Country:US
Mailing Address - Phone:407-620-7509
Mailing Address - Fax:
Practice Address - Street 1:6927 SYLVAN WOODS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-6435
Practice Address - Country:US
Practice Address - Phone:407-358-0851
Practice Address - Fax:407-358-0923
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist