Provider Demographics
NPI:1053918755
Name:MORAN, NUTTAYA
Entity type:Individual
Prefix:
First Name:NUTTAYA
Middle Name:
Last Name:MORAN
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 1:79 PLEASANT RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:POUGHQUAG
Mailing Address - State:NY
Mailing Address - Zip Code:12570
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:49 GREENWICH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:682-628-9514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT9577225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist