Provider Demographics
NPI:1699097964
Name:MOORE, SUSAN A (MS CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
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:PO BOX 34
Mailing Address - Street 2:
Mailing Address - City:NORTH HYDE PARK
Mailing Address - State:VT
Mailing Address - Zip Code:05665-0034
Mailing Address - Country:US
Mailing Address - Phone:802-888-5578
Mailing Address - Fax:
Practice Address - Street 1:114 LANGDELL ROAD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:VT
Practice Address - Zip Code:05655
Practice Address - Country:US
Practice Address - Phone:802-888-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT6 84235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist