Healthcare Provider Details

I. General information

NPI: 1598222028
Provider Name (Legal Business Name): CASSIDY MOORE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSIDY TAYLOR

II. Dates (important events)

Enumeration Date: 02/20/2019
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205B W GREEN OAKS BLVD
ARLINGTON TX
76013-8301
US

IV. Provider business mailing address

1419 LYRA LN
ARLINGTON TX
76013-8311
US

V. Phone/Fax

Practice location:
  • Phone: 817-457-3088
  • Fax:
Mailing address:
  • Phone: 940-255-9287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number106663
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: