Provider Demographics
NPI:1386037703
Name:MOON, MELISSA S (MOTR)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:S
Last Name:MOON
Suffix:
Gender:F
Credentials:MOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8241 KINDRED SPIRIT LN
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-2201
Mailing Address - Country:US
Mailing Address - Phone:941-232-8189
Mailing Address - Fax:
Practice Address - Street 1:8241 KINDRED SPIRIT LN
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-2201
Practice Address - Country:US
Practice Address - Phone:941-232-8189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT16925225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist