Provider Demographics
NPI:1871859603
Name:MOON, GREGORY A (MA, NCC, LCAS, LPC)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:A
Last Name:MOON
Suffix:
Gender:M
Credentials:MA, NCC, LCAS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19701 W CATAWBA AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4080
Mailing Address - Country:US
Mailing Address - Phone:704-989-1031
Mailing Address - Fax:704-896-7819
Practice Address - Street 1:19701 W CATAWBA AVE
Practice Address - Street 2:SUITE F
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4080
Practice Address - Country:US
Practice Address - Phone:704-989-1031
Practice Address - Fax:704-896-7819
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3337101YA0400X
NC8466101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional