Provider Demographics
NPI:1730224395
Name:MULLIGAN, MOIRA A (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:MOIRA
Middle Name:A
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 COLLEGE PARKWAY, MEDICAL OFFICE BUILDING
Mailing Address - Street 2:SUITE 102, UNIVERSITY OF VERMONT MEDICAL CENTER
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446
Mailing Address - Country:US
Mailing Address - Phone:802-847-2065
Mailing Address - Fax:
Practice Address - Street 1:792 COLLEGE PARKWAY, MEDICAL OFFICE BUILDING
Practice Address - Street 2:SUITE 102, UNIVERSITY OF VERMONT MEDICAL CENTER
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446
Practice Address - Country:US
Practice Address - Phone:802-847-2065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
01031583235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
711918OtherMVP
59895OtherBLUE CROSS BLUE SHIELD