Provider Demographics
NPI:1902018807
Name:MOOMAW, AMY MARIE (CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:MOOMAW
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 REDGATE AVE
Mailing Address - Street 2:APT D
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1344
Mailing Address - Country:US
Mailing Address - Phone:757-303-8219
Mailing Address - Fax:
Practice Address - Street 1:6401 AUBURN DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BCH
Practice Address - State:VA
Practice Address - Zip Code:23464-3601
Practice Address - Country:US
Practice Address - Phone:757-420-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2013-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202003817235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist