Healthcare Provider Details

I. General information

NPI: 1982069613
Provider Name (Legal Business Name): MOXIE SPEECH AND LANGUAGE PATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 12/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 FRONT ROYAL LN
KNOXVILLE TN
37922-5287
US

IV. Provider business mailing address

1101 FRONT ROYAL LN
KNOXVILLE TN
37922-5287
US

V. Phone/Fax

Practice location:
  • Phone: 704-564-4659
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5700
License Number StateTN

VIII. Authorized Official

Name: KRISTEN GOODMAN
Title or Position: SPEECH THERAPIST
Credential: MA CCC-SLP
Phone: 704-564-4659