Provider Demographics
NPI:1912070301
Name:RAY DEREK MUNN
Entity Type:Organization
Organization Name:RAY DEREK MUNN
Other - Org Name:AT HOME PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAY
Authorized Official - Middle Name:DEREK
Authorized Official - Last Name:MUNN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT, DPT, OCS
Authorized Official - Phone:617-306-6519
Mailing Address - Street 1:30 PLAYSTEAD RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02458-2125
Mailing Address - Country:US
Mailing Address - Phone:617-306-6519
Mailing Address - Fax:617-244-4672
Practice Address - Street 1:30 PLAYSTEAD RD
Practice Address - Street 2:SUITE #1
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02458-2125
Practice Address - Country:US
Practice Address - Phone:617-306-6519
Practice Address - Fax:617-244-4672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11262225100000X
225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PT0329OtherMEDICARE IDENTIFICATION NUMBER