Provider Demographics
NPI:1508265067
Name:MOON, NATHAN ROBERT (MA, PSYD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ROBERT
Last Name:MOON
Suffix:
Gender:M
Credentials:MA, PSYD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 17854
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367-0081
Mailing Address - Country:US
Mailing Address - Phone:801-682-0517
Mailing Address - Fax:
Practice Address - Street 1:PSC 42
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96367
Practice Address - Country:US
Practice Address - Phone:315-634-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1328103T00000X
NMPSY1328103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist