Provider Demographics
NPI:1841588761
Name:MOORE, ADAM LAWRENCE (MED, CCC-SLP)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:LAWRENCE
Last Name:MOORE
Suffix:
Gender:M
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11640 COURT OF PALMS APT 304
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-6553
Mailing Address - Country:US
Mailing Address - Phone:407-476-8629
Mailing Address - Fax:
Practice Address - Street 1:11640 COURT OF PALMS APT 304
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-6553
Practice Address - Country:US
Practice Address - Phone:407-476-8629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007671235Z00000X
NJ41YS00675000235Z00000X
LA8012235Z00000X
MD09260235Z00000X
WALL60686608235Z00000X
CA23548235Z00000X
NY16882235Z00000X
NY022453-1235Z00000X
TX106116235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist