Healthcare Provider Details

I. General information

NPI: 1093645467
Provider Name (Legal Business Name): PRIMA MARIE MOORE SLP CCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 S GLENDORA AVE
WEST COVINA CA
91790-4924
US

IV. Provider business mailing address

14071 CRESTLINE PL
RANCHO CUCAMONGA CA
91739-2140
US

V. Phone/Fax

Practice location:
  • Phone: 626-488-9707
  • Fax:
Mailing address:
  • Phone: 626-488-9707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number19389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: