Provider Demographics
NPI:1184011678
Name:MOON, SOMANG
Entity Type:Individual
Prefix:
First Name:SOMANG
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SO MANG
Other - Middle Name:
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AUD
Mailing Address - Street 1:110 CARLTON STREET 593 ADERHOLD HALL
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30602-5004
Mailing Address - Country:US
Mailing Address - Phone:706-542-4598
Mailing Address - Fax:706-249-4249
Practice Address - Street 1:110 CARLTON STREET
Practice Address - Street 2:593 ADERHOLD HALL
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30602-5004
Practice Address - Country:US
Practice Address - Phone:706-542-4598
Practice Address - Fax:706-249-4249
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80566231H00000X
UT9292723-4101231H00000X
NC13693231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist