Provider Demographics
NPI:1154844728
Name:MOON, TERRI HARRISON (CMT)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:HARRISON
Last Name:MOON
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:LYNN
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8471 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-4516
Mailing Address - Country:US
Mailing Address - Phone:707-709-8574
Mailing Address - Fax:
Practice Address - Street 1:360 TESCONI CIR STE C
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4677
Practice Address - Country:US
Practice Address - Phone:707-709-8574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44387225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA44387OtherCALIFORNIA MASSAGE THERAPY COUNCIL