Provider Demographics
NPI:1154950442
Name:MOON, ALYSSA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:ALYSSA
Other - Middle Name:
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:215 MAY LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT HUACHUCA
Mailing Address - State:AZ
Mailing Address - Zip Code:85613-1560
Mailing Address - Country:US
Mailing Address - Phone:720-284-4095
Mailing Address - Fax:
Practice Address - Street 1:5750 E HIGHWAY 90 STE 100
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-9112
Practice Address - Country:US
Practice Address - Phone:520-263-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP10395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist