Provider Demographics
NPI:1780898775
Name:MOORE, MELISSA A (SLP)
Entity type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:A
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:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:HUEYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41640-0104
Mailing Address - Country:US
Mailing Address - Phone:606-358-9283
Mailing Address - Fax:
Practice Address - Street 1:610 SOUTHERN CAMP DR
Practice Address - Street 2:
Practice Address - City:HUEYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41640-0104
Practice Address - Country:US
Practice Address - Phone:606-358-9283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1871OtherFIRST STEPS PROVIDER #
KY1342OtherSTATE SLP LICENSE #