Provider Demographics
NPI:1053975979
Name:MOORE, DAVID BRENT (MSCCC/SLP BCHIS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BRENT
Last Name:MOORE
Suffix:
Gender:M
Credentials:MSCCC/SLP BCHIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 W IOWA AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2732
Mailing Address - Country:US
Mailing Address - Phone:405-222-4444
Mailing Address - Fax:
Practice Address - Street 1:2201 W IOWA AVE STE 5
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2732
Practice Address - Country:US
Practice Address - Phone:405-222-4444
Practice Address - Fax:405-222-4402
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2184235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty