Provider Demographics
NPI:1073389771
Name:MOONSTONE MENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:MOONSTONE MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAEMKE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:719-659-5329
Mailing Address - Street 1:5745 E OLD FARM CIR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80917-1141
Mailing Address - Country:US
Mailing Address - Phone:719-659-5329
Mailing Address - Fax:
Practice Address - Street 1:5745 E OLD FARM CIR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80917-1141
Practice Address - Country:US
Practice Address - Phone:719-659-5329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty