Provider Demographics
NPI:1902255433
Name:MOON, BETHANY L (MA, SSP)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:L
Last Name:MOON
Suffix:
Gender:F
Credentials:MA, SSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 THISTLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-9352
Mailing Address - Country:US
Mailing Address - Phone:518-307-1825
Mailing Address - Fax:
Practice Address - Street 1:11 THISTLEWOOD DR
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-9352
Practice Address - Country:US
Practice Address - Phone:518-307-1825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2695385103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool