Provider Demographics
NPI:1649824236
Name:MOORE, MALLORY (SLP)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1377
Mailing Address - Country:US
Mailing Address - Phone:318-396-1969
Mailing Address - Fax:
Practice Address - Street 1:2309 S SERVICE RD W
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-3167
Practice Address - Country:US
Practice Address - Phone:318-232-1969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA8340OtherSPEECH LICENSE