Healthcare Provider Details

I. General information

NPI: 1952535817
Provider Name (Legal Business Name): TINA LOUISE MOON PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2009
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

IV. Provider business mailing address

1865 LPGA BLVD
DAYTONA BEACH FL
32117-7108
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4596
  • Fax: 386-258-3561
Mailing address:
  • Phone: 386-255-4596
  • Fax: 386-258-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT26616
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: