Provider Demographics
NPI:1114514973
Name:MOON, ELIZABETH (PHD, LMFT)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 CAROLINA AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-2311
Mailing Address - Country:US
Mailing Address - Phone:540-815-4882
Mailing Address - Fax:
Practice Address - Street 1:2707 CAROLINA AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2311
Practice Address - Country:US
Practice Address - Phone:540-815-4882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717001106106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist