Provider Demographics
NPI:1932363298
Name:MOORE, ANDREA R (MA, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 BOARDMAN CANFIELD RD
Mailing Address - Street 2:E-1
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4380
Mailing Address - Country:US
Mailing Address - Phone:330-307-7983
Mailing Address - Fax:
Practice Address - Street 1:725 BOARDMAN CANFIELD RD
Practice Address - Street 2:E-1
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4380
Practice Address - Country:US
Practice Address - Phone:330-307-7983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP7959235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH11685184OtherCAQH
OH000000175073OtherUNISON
OH000000175073OtherUNISON