Provider Demographics
NPI:1851394902
Name:MOORE, STACIA ADAIR (AUD)
Entity Type:Individual
Prefix:DR
First Name:STACIA
Middle Name:ADAIR
Last Name:MOORE
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 THREE MILE DR
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-3034
Mailing Address - Country:US
Mailing Address - Phone:406-257-2273
Mailing Address - Fax:406-257-7755
Practice Address - Street 1:10 THREE MILE DR
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3034
Practice Address - Country:US
Practice Address - Phone:406-257-2273
Practice Address - Fax:406-257-7755
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTAU795231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0561629Medicaid
MT0533851Medicaid
MT290408OtherBLUE CROSS BLUE SHIELD
MT0533851Medicaid