Provider Demographics
NPI:1538173349
Name:MOORE, ROBERT STROUD (MA-CCC-A)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:STROUD
Last Name:MOORE
Suffix:
Gender:M
Credentials:MA-CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2359 HWY 1 SOUTH
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701
Mailing Address - Country:US
Mailing Address - Phone:662-335-9434
Mailing Address - Fax:662-335-9464
Practice Address - Street 1:2359 HWY 1 SOUTH
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701
Practice Address - Country:US
Practice Address - Phone:662-335-9434
Practice Address - Fax:662-335-9464
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA2092231H00000X
MSHA0470237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770235Medicaid
MS640000018Medicare ID - Type Unspecified