Provider Demographics
NPI:1891014353
Name:MOON, DEBORAH (PT)
Entity type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:M
Other - Last Name:VERGARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1223 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1427
Mailing Address - Country:US
Mailing Address - Phone:928-777-9950
Mailing Address - Fax:928-777-9975
Practice Address - Street 1:1223 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1427
Practice Address - Country:US
Practice Address - Phone:928-777-9950
Practice Address - Fax:928-777-9975
Is Sole Proprietor?:No
Enumeration Date:2010-05-24
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2445225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ354655Medicaid
AZZ195839Medicare PIN