Provider Demographics
NPI:1407676711
Name:MOOG, LORRAINE KAREN
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:KAREN
Last Name:MOOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 DEEPDALE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9020
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1363 VETERANS HWY STE 33
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3046
Practice Address - Country:US
Practice Address - Phone:631-882-2517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006728225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty