Provider Demographics
NPI:1003824194
Name:MOON, EDWARD TINDAL (PSY D)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:TINDAL
Last Name:MOON
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 S 17TH ST
Mailing Address - Street 2:SUITE 2301
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6231
Mailing Address - Country:US
Mailing Address - Phone:610-659-0774
Mailing Address - Fax:
Practice Address - Street 1:255 S 17TH ST
Practice Address - Street 2:SUITE 2301
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6231
Practice Address - Country:US
Practice Address - Phone:610-659-0774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007695L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical