=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184195455
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAWN MARIE LUELLEN MOON PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2018
-----------------------------------------------------
Last Update Date | 03/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 NALLEY TER
-----------------------------------------------------
City | LANDOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-4434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-975-1536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2002 CALLAWAY ST
-----------------------------------------------------
City | TEMPLE HILLS
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20748-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-702-3870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 20655
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------