Provider Demographics
NPI:1558774422
Name:HALF MOON MEDICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:HALF MOON MEDICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:NCC, LPC, LCAS
Authorized Official - Phone:704-989-1031
Mailing Address - Street 1:19701 W CATAWBA AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4080
Mailing Address - Country:US
Mailing Address - Phone:704-895-7819
Mailing Address - Fax:704-896-7819
Practice Address - Street 1:19701 W CATAWBA AVE
Practice Address - Street 2:SUITE F
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4080
Practice Address - Country:US
Practice Address - Phone:704-895-7819
Practice Address - Fax:704-896-7819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-08
Last Update Date:2014-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3337101YA0400X
NC8466101YM0800X, 101YP2500X
NC39164207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty