Provider Demographics
NPI:1942508734
Name:MOON, RICHARD DAVID (PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DAVID
Last Name:MOON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CLINTON TER
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880-6019
Mailing Address - Country:US
Mailing Address - Phone:203-222-1192
Mailing Address - Fax:
Practice Address - Street 1:1106 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2710
Practice Address - Country:US
Practice Address - Phone:203-579-6131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001589103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist