Provider Demographics
NPI:1285120931
Name:MOORE, BRANDI ALISHIA (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:ALISHIA
Last Name:MOORE
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 1:2916 CLAIRMONT RD NE APT 3102
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-4483
Mailing Address - Country:US
Mailing Address - Phone:678-353-1955
Mailing Address - Fax:
Practice Address - Street 1:404 KING SPRINGS VILLAGE PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4203
Practice Address - Country:US
Practice Address - Phone:678-353-1955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist