Provider Demographics
NPI:1811563604
Name:MOON WELLNESS GROUP, PLLC
Entity Type:Organization
Organization Name:MOON WELLNESS GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHD
Authorized Official - Prefix:
Authorized Official - First Name:MIEA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-681-0830
Mailing Address - Street 1:3240 OLD HICKORY PL
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-5279
Mailing Address - Country:US
Mailing Address - Phone:734-707-3770
Mailing Address - Fax:
Practice Address - Street 1:2385 S HURON PKWY STE 2N
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-5127
Practice Address - Country:US
Practice Address - Phone:734-681-0830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty