Provider Demographics
NPI:1669682035
Name:MOORE, JANICE LYNN (MSC CCCSLP)
Entity type:Individual
Prefix:MS
First Name:JANICE
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSC CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 TIMBER LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-1535
Mailing Address - Country:US
Mailing Address - Phone:864-235-1393
Mailing Address - Fax:
Practice Address - Street 1:1700 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4730
Practice Address - Country:US
Practice Address - Phone:864-288-2390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC943235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0092Medicaid