Provider Demographics
NPI:1972747491
Name:MOORE, CONNIE SUSAN (MS,CCC/SLP)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:SUSAN
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 1:409 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:IL
Mailing Address - Zip Code:62839-2503
Mailing Address - Country:US
Mailing Address - Phone:618-662-8934
Mailing Address - Fax:
Practice Address - Street 1:1201 HAWTHORN RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1028
Practice Address - Country:US
Practice Address - Phone:618-548-4884
Practice Address - Fax:618-548-2150
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL12098284235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist