Provider Demographics
NPI:1275153124
Name:WARD-MOON, TINA (CDCA 181013)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WARD-MOON
Suffix:
Gender:F
Credentials:CDCA 181013
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-1304
Mailing Address - Country:US
Mailing Address - Phone:216-391-6672
Mailing Address - Fax:
Practice Address - Street 1:3355 RICHMOND RD STE 225A
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4180
Practice Address - Country:US
Practice Address - Phone:216-831-1494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-21
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
OH181013101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker