Provider Demographics
NPI:1952532301
Name:MOON, ANDREA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
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 1:103 JASON ST
Mailing Address - Street 2:
Mailing Address - City:AVOCA
Mailing Address - State:PA
Mailing Address - Zip Code:18641-1127
Mailing Address - Country:US
Mailing Address - Phone:570-789-1189
Mailing Address - Fax:
Practice Address - Street 1:616 MOUNTAIN VALLEY RD
Practice Address - Street 2:
Practice Address - City:HALLSTEAD
Practice Address - State:PA
Practice Address - Zip Code:18822-9169
Practice Address - Country:US
Practice Address - Phone:607-761-3487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC011121225XP0200X
NY015762-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics