Provider Demographics
NPI:1780919506
Name:MOON, VIRGINIA ELLEN (MS)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:ELLEN
Last Name:MOON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 SOUTH 16TH COURT
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982
Mailing Address - Country:US
Mailing Address - Phone:920-787-6710
Mailing Address - Fax:
Practice Address - Street 1:203 SOUTH 16TH COURT
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982
Practice Address - Country:US
Practice Address - Phone:920-787-6710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health