Provider Demographics
NPI:1811495500
Name:MOORE, KATHRYN GRAGE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:GRAGE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:INGERSOLL
Other - Last Name:GRAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:3200 POINTE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CORNERS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3370
Mailing Address - Country:US
Mailing Address - Phone:770-639-1172
Mailing Address - Fax:
Practice Address - Street 1:3200 POINTE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-3370
Practice Address - Country:US
Practice Address - Phone:770-639-1172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-27
Last Update Date:2018-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008015235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist