Provider Demographics
NPI:1568934875
Name:MOONRISE THERAPEUTICS, INC.
Entity Type:Organization
Organization Name:MOONRISE THERAPEUTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:JESSER
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:802-345-5637
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:TAFTSVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05073-0090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:41 WHITCOMB LANE
Practice Address - Street 2:
Practice Address - City:TAFTSVILLE
Practice Address - State:VT
Practice Address - Zip Code:05073
Practice Address - Country:US
Practice Address - Phone:802-345-5637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty