Provider Demographics
NPI:1891764940
Name:MOON, JOHN A (LSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:MOON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-1237
Mailing Address - Country:US
Mailing Address - Phone:740-826-4353
Mailing Address - Fax:
Practice Address - Street 1:710 MAIN ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1615
Practice Address - Country:US
Practice Address - Phone:740-454-9766
Practice Address - Fax:740-588-6452
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0010829104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH318201OtherMOUNT CARMEL PIN