MEDICARE: MRS. AMY MARIE MOOMAW CCC.SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	2202003817	VA

General Provider Information

NPI Number	:	1902018807
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AMY MARIE MOOMAW CCC.SLP

Provider Business Mailing Address
First Line	:	1214 REDGATE AVE
Second Line	:	APT D
City	:	NORFOLK
State	:	VA
Zip	:	23507-1344
Country	:	US
Telephone Number	:	757-303-8219
Fax Number	:

Provider Business Practice Location Address
First Line	:	6401 AUBURN DR
Second Line	:
City	:	VIRGINIA BCH
State	:	VA
Zip	:	23464-3601
Country	:	US
Telephone Number	:	757-420-1485
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2007
Last Update Date	:	02/02/2013

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