Provider Demographics
NPI:1851608988
Name:MOODY, DOREEN R (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:R
Last Name:MOODY
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CATELL ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6802
Mailing Address - Country:US
Mailing Address - Phone:207-990-2093
Mailing Address - Fax:
Practice Address - Street 1:63 ELM STREET
Practice Address - Street 2:
Practice Address - City:HEARTLAND
Practice Address - State:ME
Practice Address - Zip Code:04943
Practice Address - Country:US
Practice Address - Phone:207-368-5146
Practice Address - Fax:207-368-2192
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP789235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESP789OtherSPEECH-LANGUAGE PATHOLOGY