Healthcare Provider Details

I. General information

NPI: 1295419497
Provider Name (Legal Business Name): JOHN ROBERT MOYNIHAN DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E NORTHWEST HWY
PALATINE IL
60067-8116
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 847-701-1930
  • Fax: 847-701-1931
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.028378
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16291-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: