Provider Demographics
NPI:1205319472
Name:BLUE MOON THERAPY LLC
Entity type:Organization
Organization Name:BLUE MOON THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:LSCSW
Authorized Official - Phone:316-249-4447
Mailing Address - Street 1:1215 E JUMP ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67216-1360
Mailing Address - Country:US
Mailing Address - Phone:316-249-4447
Mailing Address - Fax:
Practice Address - Street 1:400 N WOODLAWN
Practice Address - Street 2:SUITE 100
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67216-1360
Practice Address - Country:US
Practice Address - Phone:316-652-2580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)