Provider Demographics
NPI:1003374356
Name:FUTURE MOONS
Entity type:Organization
Organization Name:FUTURE MOONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMFT
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:310-600-2037
Mailing Address - Street 1:1614 AVALON ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-1816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1511 PARMER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-2621
Practice Address - Country:US
Practice Address - Phone:310-600-2037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106513OtherLICENSE NUMBER