Provider Demographics
NPI:1053566539
Name:MOORE, KEELEY RAE (MA CCC-A)
Entity type:Individual
Prefix:
First Name:KEELEY
Middle Name:RAE
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 W. 183RD ST.
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430
Mailing Address - Country:US
Mailing Address - Phone:708-957-7122
Mailing Address - Fax:708-957-7495
Practice Address - Street 1:2920 W. 183RD ST.
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430
Practice Address - Country:US
Practice Address - Phone:708-957-7122
Practice Address - Fax:708-957-7495
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000932231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter