Provider Demographics
NPI:1669860987
Name:MOON, NATASHA (MA, LPC)
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 TERRITORIAL RD
Mailing Address - Street 2:
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251-9614
Mailing Address - Country:US
Mailing Address - Phone:517-262-6959
Mailing Address - Fax:
Practice Address - Street 1:505 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1266
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional