Provider Demographics
NPI:1164656815
Name:MOONRIDGE ACADEMY
Entity type:Organization
Organization Name:MOONRIDGE ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAWNY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:435-890-9180
Mailing Address - Street 1:9450 W 2400 S
Mailing Address - Street 2:P.O. BOX 1067
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-6706
Mailing Address - Country:US
Mailing Address - Phone:435-586-9585
Mailing Address - Fax:435-586-4489
Practice Address - Street 1:9450 W 2400 S
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-6706
Practice Address - Country:US
Practice Address - Phone:435-586-9585
Practice Address - Fax:435-586-4489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12809322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children