Provider Demographics
NPI:1295426658
Name:MOON, KAYLA GRACE (OTR/L)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:GRACE
Last Name:MOON
Suffix:
Gender:
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 1:12319 WATERSTONE LN APT 416
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-3049
Mailing Address - Country:US
Mailing Address - Phone:513-571-1896
Mailing Address - Fax:
Practice Address - Street 1:422 HUFFMAN MILL RD STE 121
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-5194
Practice Address - Country:US
Practice Address - Phone:530-433-6270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15869225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist