Provider Demographics
NPI:1902271620
Name:OVER THE MOON ENRICHMENT AGENCY
Entity Type:Organization
Organization Name:OVER THE MOON ENRICHMENT AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/EI PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-524-4411
Mailing Address - Street 1:PO BOX 1201
Mailing Address - Street 2:
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566
Mailing Address - Country:US
Mailing Address - Phone:845-524-4411
Mailing Address - Fax:
Practice Address - Street 1:61 A MAIN STREET
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566
Practice Address - Country:US
Practice Address - Phone:845-524-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency