Provider Demographics
NPI:1972075661
Name:MOONLIGHT PSYCHOTHERAPY AND PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:MOONLIGHT PSYCHOTHERAPY AND PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:207-317-0557
Mailing Address - Street 1:1718 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-7030
Mailing Address - Country:US
Mailing Address - Phone:207-317-0557
Mailing Address - Fax:
Practice Address - Street 1:205 5TH AVE S STE 428
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-4059
Practice Address - Country:US
Practice Address - Phone:207-317-0557
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty