Provider Demographics
NPI:1538671250
Name:MOON, MIEA (MA, PHD)
Entity Type:Individual
Prefix:DR
First Name:MIEA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:MA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 OLD HICKORY PL
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5279
Mailing Address - Country:US
Mailing Address - Phone:734-707-3770
Mailing Address - Fax:
Practice Address - Street 1:2385 S HURON PKWY
Practice Address - Street 2:STE 2N
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5127
Practice Address - Country:US
Practice Address - Phone:734-677-0070
Practice Address - Fax:734-677-0070
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016960103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist