Provider Demographics
NPI:1205049152
Name:MOORE, DEIDRE ANN (CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:DEIDRE
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials: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:PO BOX 40696
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-0696
Mailing Address - Country:US
Mailing Address - Phone:765-621-3285
Mailing Address - Fax:317-218-3462
Practice Address - Street 1:1060 E 86TH ST
Practice Address - Street 2:SUITE 65C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1863
Practice Address - Country:US
Practice Address - Phone:765-621-3285
Practice Address - Fax:317-218-3462
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002523A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist