Provider Demographics
NPI:1245811686
Name:MOON, SUSANNA SOL (MSOT, OTR/L)
Entity type:Individual
Prefix:
First Name:SUSANNA
Middle Name:SOL
Last Name:MOON
Suffix:
Gender:F
Credentials:MSOT, OTR/L
Other - Prefix:
Other - First Name:SUSANNA
Other - Middle Name:SOL
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10591 LAKESIDE DR S UNIT I
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5081
Mailing Address - Country:US
Mailing Address - Phone:951-215-5545
Mailing Address - Fax:
Practice Address - Street 1:8282 WHITE OAK AVE STE 107
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7681
Practice Address - Country:US
Practice Address - Phone:909-586-0509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22111225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist