Provider Demographics
NPI:1679186514
Name:MOON, TRACY NICOLE (OTD, OTR/L)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:NICOLE
Last Name:MOON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3649 BELMONT HWY
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30507-8953
Mailing Address - Country:US
Mailing Address - Phone:784-257-4676
Mailing Address - Fax:
Practice Address - Street 1:3000 CELEBRATION BLVD
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1054
Practice Address - Country:US
Practice Address - Phone:678-425-7467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist