Provider Demographics
NPI:1003420522
Name:CACAPON CENTER FOR GROWTH, PLLC
Entity Type:Organization
Organization Name:CACAPON CENTER FOR GROWTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW
Authorized Official - Phone:304-702-4426
Mailing Address - Street 1:1855 VALLEY RD # 368
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-4816
Mailing Address - Country:US
Mailing Address - Phone:304-702-4426
Mailing Address - Fax:
Practice Address - Street 1:144 GROVE HEIGHTS ROAD
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25411-4816
Practice Address - Country:US
Practice Address - Phone:304-500-8133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health