Provider Demographics
NPI:1386082816
Name:MOORE, AMY RAE (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:RAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 DUNDAS DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8502
Mailing Address - Country:US
Mailing Address - Phone:904-757-1782
Mailing Address - Fax:904-757-9808
Practice Address - Street 1:320 DUNDAS DR
Practice Address - Street 2:SUITE 8
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-8502
Practice Address - Country:US
Practice Address - Phone:904-757-1782
Practice Address - Fax:904-757-9808
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-06
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist