Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 9476 | GA |
N | 2251P0200X | Physical Therapist - Pediatrics | 9476 | GA |
NPI | 1053564559 |
---|---|
Provider Name | Lindsay Moon |
First Address | Marietta, GA 30066-0121 |
Second Address | Marietta, GA 30066-1541 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2008 |
Last Update Date | 28/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
9476 | PHYSICAL THERAPY LICENSE (01) | GA |