Provider Demographics
NPI:1891385266
Name:MOON, KELSEY (MA, LPC-IT)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:MA, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W7327 ANDERSON AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-1143
Mailing Address - Country:US
Mailing Address - Phone:715-524-6882
Mailing Address - Fax:
Practice Address - Street 1:W7327 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-1143
Practice Address - Country:US
Practice Address - Phone:715-526-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4852-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health