Provider Demographics
NPI:1942781299
Name:MOON, KEVIN DOUGLAS (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DOUGLAS
Last Name:MOON
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 RAINTREE IS APT 3
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-2736
Mailing Address - Country:US
Mailing Address - Phone:845-558-5871
Mailing Address - Fax:
Practice Address - Street 1:3767 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1040
Practice Address - Country:US
Practice Address - Phone:716-874-6175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022807225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist