Provider Demographics
NPI:1457959835
Name:MOORE, KRISTIN
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 S SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86303-4115
Mailing Address - Country:US
Mailing Address - Phone:360-281-2025
Mailing Address - Fax:
Practice Address - Street 1:311 S SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4115
Practice Address - Country:US
Practice Address - Phone:360-281-2025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP12656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist