MEDICARE: MS. LAURIE ANN MOON LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	016941	NY

General Provider Information

NPI Number	:	1841447042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURIE ANN MOON LMT

Provider Business Mailing Address
First Line	:	101 DAVIS AVE APT 2
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10310-3224
Country	:	US
Telephone Number	:	917-767-9525
Fax Number	:

Provider Business Practice Location Address
First Line	:	1332 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2012
Country	:	US
Telephone Number	:	917-767-9525
Fax Number	:	888-522-3203

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2008
Last Update Date	:	02/09/2018

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