Provider Demographics
NPI:1386395648
Name:MOORE, ANGIE SUZANNE (SLP)
Entity type:Individual
Prefix:
First Name:ANGIE
Middle Name:SUZANNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 ROCKY BAY LN
Mailing Address - Street 2:
Mailing Address - City:SENOIA
Mailing Address - State:GA
Mailing Address - Zip Code:30276-6721
Mailing Address - Country:US
Mailing Address - Phone:770-599-4490
Mailing Address - Fax:
Practice Address - Street 1:324 STEVENS ENTRY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1325
Practice Address - Country:US
Practice Address - Phone:678-619-0178
Practice Address - Fax:678-701-1139
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004851235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist