Provider Demographics
NPI:1023742442
Name:MOORE, KATHLEEN GRACE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:GRACE
Last Name:MOORE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 CHALCEDONY ST APT 17
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3205
Mailing Address - Country:US
Mailing Address - Phone:309-265-3398
Mailing Address - Fax:
Practice Address - Street 1:7525 METROPOLITAN DR STE 308
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4412
Practice Address - Country:US
Practice Address - Phone:619-692-0622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist