Provider Demographics
NPI:1295815249
Name:MOON, TAE-IM (PHD)
Entity Type:Individual
Prefix:MS
First Name:TAE-IM
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 GEORGE WASHINGTON WAY
Mailing Address - Street 2:SUITE 8
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-946-7012
Mailing Address - Fax:509-946-8475
Practice Address - Street 1:750 GEORGE WASHINGTON WAY
Practice Address - Street 2:SUITE 8
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352
Practice Address - Country:US
Practice Address - Phone:509-946-7012
Practice Address - Fax:509-946-8475
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1767103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical