Provider Demographics
NPI:1770139800
Name:RUTHERFORD, ALICIA MOORE
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MOORE
Last Name:RUTHERFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2209 HYDE DR APT H
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-8067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2885
Practice Address - Country:US
Practice Address - Phone:252-830-2149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1876231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist