Provider Demographics
NPI:1730589334
Name:MOON, LISA (PH D)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 SOUNDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23832-7784
Mailing Address - Country:US
Mailing Address - Phone:804-683-8651
Mailing Address - Fax:804-674-4164
Practice Address - Street 1:2025 E MAIN ST
Practice Address - Street 2:SUITE 207C
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-7069
Practice Address - Country:US
Practice Address - Phone:804-683-8651
Practice Address - Fax:804-674-4164
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000002103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical