Provider Demographics
NPI:1982898912
Name:MOFFATT, ROSE ANN (MCSD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:ANN
Last Name:MOFFATT
Suffix:
Gender:F
Credentials:MCSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4042
Mailing Address - Country:US
Mailing Address - Phone:406-543-4526
Mailing Address - Fax:
Practice Address - Street 1:542 WOODFORD ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-4042
Practice Address - Country:US
Practice Address - Phone:406-543-4526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-03
Last Update Date:2007-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT528235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0535418Medicaid