Provider Demographics
NPI:1295827590
Name:MOEN, KANDYCE (OTR)
Entity Type:Individual
Prefix:
First Name:KANDYCE
Middle Name:
Last Name:MOEN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:KANDYCE
Other - Middle Name:
Other - Last Name:KUBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10069 STACY TRL
Mailing Address - Street 2:
Mailing Address - City:CHISAGO CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55013-9531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10069 STACY TRL
Practice Address - Street 2:
Practice Address - City:CHISAGO CITY
Practice Address - State:MN
Practice Address - Zip Code:55013-9531
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100563225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN05G60MOOtherBCBS
MNHP45836OtherHEALTH PARTNERS
MN6402785OtherMEDICA
MN6402785OtherMEDICA