Provider Demographics
NPI:1841562931
Name:BLUE MOON SENIOR COUNSELING OF ILLINOIS LLC
Entity Type:Organization
Organization Name:BLUE MOON SENIOR COUNSELING OF ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOHUE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:855-241-7160
Mailing Address - Street 1:10204 BODE ST STE B
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9813
Mailing Address - Country:US
Mailing Address - Phone:855-241-7160
Mailing Address - Fax:954-324-8354
Practice Address - Street 1:10204 BODE ST STE B
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9813
Practice Address - Country:US
Practice Address - Phone:855-241-7160
Practice Address - Fax:954-465-5142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL7187OtherMEDICARE PTAN