Provider Demographics
NPI:1790401735
Name:MOONSTONE PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:MOONSTONE PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAK-DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:317-564-9797
Mailing Address - Street 1:1905 S NEW MARKET ST STE 260
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7424
Mailing Address - Country:US
Mailing Address - Phone:317-564-9797
Mailing Address - Fax:877-401-3034
Practice Address - Street 1:1905 S NEW MARKET ST STE 260
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7424
Practice Address - Country:US
Practice Address - Phone:317-564-9797
Practice Address - Fax:877-401-3034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty