Provider Demographics
NPI:1770693293
Name:MOON, DENISE (PT)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 GRAND ST APT 2
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2406
Mailing Address - Country:US
Mailing Address - Phone:201-988-4815
Mailing Address - Fax:
Practice Address - Street 1:501 FAIRMOUNT AVE
Practice Address - Street 2:STE 302
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5457
Practice Address - Country:US
Practice Address - Phone:410-927-8768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01124500225100000X
MD23506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD23506OtherLICENSE
NJ40QA01124500OtherLICENSE #