Provider Demographics
NPI:1780619056
Name:MOORE, CAROLINE B (ST)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:B
Last Name:MOORE
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP
Mailing Address - Street 2:STE 604
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4436
Mailing Address - Country:US
Mailing Address - Phone:731-660-8755
Mailing Address - Fax:
Practice Address - Street 1:32 GARLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3602
Practice Address - Country:US
Practice Address - Phone:731-664-3645
Practice Address - Fax:731-668-6549
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2912235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist