Provider Demographics
NPI:1992013734
Name:MOONEY, KEVIN MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:MICHAEL
Last Name:MOONEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BERKSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:MA
Mailing Address - Zip Code:02056-1942
Mailing Address - Country:US
Mailing Address - Phone:646-281-3872
Mailing Address - Fax:
Practice Address - Street 1:11 BERKSHIRE ST
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:MA
Practice Address - Zip Code:02056-1942
Practice Address - Country:US
Practice Address - Phone:646-281-3872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist