Provider Demographics
NPI:1184272791
Name:MOONEY, INDIA R (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:INDIA
Middle Name:R
Last Name:MOONEY
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6515
Mailing Address - Country:US
Mailing Address - Phone:313-255-8267
Mailing Address - Fax:313-242-0490
Practice Address - Street 1:12200 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3093
Practice Address - Country:US
Practice Address - Phone:313-255-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-27
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401019217101YP2500X, 101Y00000X, 101YM0800X
390200000X
MI6401223867101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6344Medicaid