Provider Demographics
NPI:1790466969
Name:MOONEY, ETHAN ANDREW (ATC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:ANDREW
Last Name:MOONEY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3320 DAIRY RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-7604
Mailing Address - Country:US
Mailing Address - Phone:321-745-0579
Mailing Address - Fax:
Practice Address - Street 1:3320 DAIRY RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-7604
Practice Address - Country:US
Practice Address - Phone:321-745-0579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL70002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer