Provider Demographics
NPI:1497199541
Name:MOON, STEPHANIE A
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:A
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 BUCK RD
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-2720
Mailing Address - Country:US
Mailing Address - Phone:434-205-4333
Mailing Address - Fax:434-205-4016
Practice Address - Street 1:1675 BUCK RD
Practice Address - Street 2:
Practice Address - City:CROZET
Practice Address - State:VA
Practice Address - Zip Code:22932-2720
Practice Address - Country:US
Practice Address - Phone:434-205-4333
Practice Address - Fax:434-205-4016
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-19
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA274236485OtherFEDERAL I D