Provider Demographics
NPI:1285134486
Name:MOON, AMY MARIE (PTA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:MOON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 WINDCREST DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-9750
Mailing Address - Country:US
Mailing Address - Phone:630-779-2370
Mailing Address - Fax:
Practice Address - Street 1:1340 N RIVER ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1477
Practice Address - Country:US
Practice Address - Phone:630-892-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.003950225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant