Provider Demographics
NPI:1104680339
Name:MOON, MADELEINE
Entity type:Individual
Prefix:
First Name:MADELEINE
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELEINE
Other - Middle Name:
Other - Last Name:BOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5401 HERITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5401 HERITAGE AVE
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5919
Practice Address - Country:US
Practice Address - Phone:817-305-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121729235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist