Provider Demographics
NPI:1184195455
Name:MOON, DAWN MARIE LUELLEN (PT)
Entity Type:Individual
Prefix:DR
First Name:DAWN MARIE
Middle Name:LUELLEN
Last Name:MOON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 CALLAWAY ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE HILLS
Mailing Address - State:MD
Mailing Address - Zip Code:20748-4353
Mailing Address - Country:US
Mailing Address - Phone:301-702-3870
Mailing Address - Fax:
Practice Address - Street 1:1400 NALLEY TER
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-4434
Practice Address - Country:US
Practice Address - Phone:443-975-1536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD20655225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist