Provider Demographics
NPI:1023996741
Name:MOOBERRY, MATTHEW WAYNE (MA SLP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:WAYNE
Last Name:MOOBERRY
Suffix:
Gender:M
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10656 RING AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-4416
Mailing Address - Country:US
Mailing Address - Phone:909-731-7965
Mailing Address - Fax:
Practice Address - Street 1:1371 HECLA DR STE D130
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-2318
Practice Address - Country:US
Practice Address - Phone:303-963-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0001474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist