Provider Demographics
NPI:1093597619
Name:BEAUTIFUL MOON HEALTH & WELLNESS, LTD.
Entity Type:Organization
Organization Name:BEAUTIFUL MOON HEALTH & WELLNESS, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAVONNI
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:510-256-9794
Mailing Address - Street 1:18121 E HAMPDEN AVE STE C1079
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80013-3590
Mailing Address - Country:US
Mailing Address - Phone:720-544-3801
Mailing Address - Fax:
Practice Address - Street 1:19590 E MAINSTREET STE 202
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-7371
Practice Address - Country:US
Practice Address - Phone:720-544-3801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No172M00000XOther Service ProvidersMechanotherapistGroup - Multi-Specialty