Provider Demographics
NPI:1962902460
Name:MOORE, MALIA
Entity type:Individual
Prefix:
First Name:MALIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 MOUNTAIN CIR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-4147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1105 27TH ST
Practice Address - Street 2:
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-2710
Practice Address - Country:US
Practice Address - Phone:360-293-3174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60631049235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60631049OtherWASHINGTON STATE DEPT OF HEALTH