Provider Demographics
NPI:1720580053
Name:MOONRISE MENTAL HEALTH PLLC
Entity Type:Organization
Organization Name:MOONRISE MENTAL HEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN METER
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, RN, PMHNP, WHNP
Authorized Official - Phone:903-918-2123
Mailing Address - Street 1:734 COUNTY ROAD 411
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:TX
Mailing Address - Zip Code:75643-5435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3516 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-8732
Practice Address - Country:US
Practice Address - Phone:936-564-9785
Practice Address - Fax:936-564-4136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111655363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty