Provider Demographics
NPI:1568759215
Name:MOON, STEPHEN L (CATC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:MOON
Suffix:
Gender:M
Credentials:CATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2042
Mailing Address - Country:US
Mailing Address - Phone:650-288-2316
Mailing Address - Fax:
Practice Address - Street 1:310 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-4018
Practice Address - Country:US
Practice Address - Phone:650-802-5191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC.A.T.C 112305101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA112305OtherTHE CALIFORNIA ASSOCIATION FOR ALCOHOL & DRUG EDUCATORS