=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912070301
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RAY DEREK MUNN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2006
-----------------------------------------------------
Last Update Date | 10/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 PLAYSTEAD RD SUITE #1
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02458-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-306-6519
-----------------------------------------------------
Fax | 617-244-4672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 PLAYSTEAD RD SUITE #1
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02458-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-306-6519
-----------------------------------------------------
Fax | 617-244-4672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RAY DEREK MUNN
-----------------------------------------------------
Credential | PT, MPT, DPT, OCS
-----------------------------------------------------
Telephone | 617-306-6519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 11262
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------