1467891861 NPI number — ELLIE CAROLINE MOON CFY-SLP

Table of content: ELLIE CAROLINE MOON CFY-SLP (NPI 1467891861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467891861 NPI number — ELLIE CAROLINE MOON CFY-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOON
Provider First Name:
ELLIE
Provider Middle Name:
CAROLINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFY-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467891861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRUITA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81521-0130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-858-3900
Provider Business Mailing Address Fax Number:
970-858-2208

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 KOKOPELLI BLVD UNIT E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-858-2526
Provider Business Practice Location Address Fax Number:
970-858-8244
Provider Enumeration Date:
06/19/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP.0003431 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)