Provider Demographics
NPI:1770770760
Name:MOORE, LORI S (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:S
Other - Last Name:BOOHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:404 OLD MAIN DR
Mailing Address - Street 2:
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1360
Mailing Address - Country:US
Mailing Address - Phone:304-872-6440
Mailing Address - Fax:
Practice Address - Street 1:404 OLD MAIN DR
Practice Address - Street 2:
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1360
Practice Address - Country:US
Practice Address - Phone:304-872-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0495235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0154297000Medicaid