Provider Demographics
NPI:1861149510
Name:TO THE MOON PLLC
Entity type:Organization
Organization Name:TO THE MOON PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BCBA
Authorized Official - Prefix:
Authorized Official - First Name:LIZNA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHIMANI
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:804-728-8827
Mailing Address - Street 1:14497 POTOMAC MILLS RD # 1013
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-6807
Mailing Address - Country:US
Mailing Address - Phone:804-728-8882
Mailing Address - Fax:
Practice Address - Street 1:10307 PEBBLEBROOK PL
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23238-6807
Practice Address - Country:US
Practice Address - Phone:804-728-8882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-02
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities