Provider Demographics
NPI:1073686820
Name:MOORE, CHELSE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CHELSE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials: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:PO BOX 723
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237-0723
Mailing Address - Country:US
Mailing Address - Phone:770-506-9676
Mailing Address - Fax:770-506-9677
Practice Address - Street 1:555 SERENE WATERS TRL
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-5497
Practice Address - Country:US
Practice Address - Phone:770-506-9676
Practice Address - Fax:770-506-9677
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist