Provider Demographics
NPI:1629147889
Name:MOON, KAREN MELISSA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:MELISSA
Last Name:MOON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2733 N VILLA BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3333
Mailing Address - Country:US
Mailing Address - Phone:479-841-6536
Mailing Address - Fax:
Practice Address - Street 1:26 E MEADOW ST STE 9
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5357
Practice Address - Country:US
Practice Address - Phone:479-368-0036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5498-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X078Medicare ID - Type Unspecified