Provider Demographics
NPI:1023706934
Name:BLUE MOON THERAPY
Entity type:Organization
Organization Name:BLUE MOON THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:MENSING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:502-654-8255
Mailing Address - Street 1:801 BARRET AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1733
Mailing Address - Country:US
Mailing Address - Phone:502-836-0759
Mailing Address - Fax:502-586-7147
Practice Address - Street 1:801 BARRET AVE STE 210
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1733
Practice Address - Country:US
Practice Address - Phone:502-836-0759
Practice Address - Fax:502-586-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-27
Last Update Date:2025-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300087737Medicaid
KY7100939560Medicaid