MEDICARE: DR. DAWN MARIE LUELLEN MOON PT

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	225100000X	Physical Therapist	20655	MD

General Provider Information

NPI Number	:	1184195455
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAWN MARIE LUELLEN MOON PT

Provider Business Mailing Address
First Line	:	2002 CALLAWAY ST
Second Line	:
City	:	TEMPLE HILLS
State	:	MD
Zip	:	20748-4353
Country	:	US
Telephone Number	:	301-702-3870
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 NALLEY TER
Second Line	:
City	:	LANDOVER
State	:	MD
Zip	:	20785-4434
Country	:	US
Telephone Number	:	443-975-1536
Fax Number	:

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

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	03/08/2019

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