Provider Demographics
NPI:1336580950
Name:MOORE, MALLORY NICOLE (SLP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICOLE
Last Name:MOORE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 INDEPENDENCE PT STE 212
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4536
Mailing Address - Country:US
Mailing Address - Phone:864-797-6252
Mailing Address - Fax:
Practice Address - Street 1:101 CHAPMAN HILL RD STE 101
Practice Address - Street 2:
Practice Address - City:CLEMSON
Practice Address - State:SC
Practice Address - Zip Code:29631-2194
Practice Address - Country:US
Practice Address - Phone:864-653-4071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9698235Z00000X
SC7188235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist