Provider Demographics
NPI:1932430139
Name:MOOSMAN, MOLLY WALKER (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:WALKER
Last Name:MOOSMAN
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 1:125 S 1300 E APT 4
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1741
Mailing Address - Country:US
Mailing Address - Phone:925-209-1696
Mailing Address - Fax:
Practice Address - Street 1:1825 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2948
Practice Address - Country:US
Practice Address - Phone:925-209-1696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7016015-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist