Provider Demographics
NPI:1326119033
Name:MOON, TERRY L (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:L
Last Name:MOON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 W COLONIAL HWY
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:VA
Mailing Address - Zip Code:20158-9002
Mailing Address - Country:US
Mailing Address - Phone:540-338-4361
Mailing Address - Fax:
Practice Address - Street 1:210 WIRT ST SW
Practice Address - Street 2:SUITE 303
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-2929
Practice Address - Country:US
Practice Address - Phone:540-338-6491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040048631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical