Provider Demographics
NPI:1184939019
Name:THERESA MOON
Entity type:Organization
Organization Name:THERESA MOON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SERVICE FACILITATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-821-2114
Mailing Address - Street 1:565 LYNBROOK RD
Mailing Address - Street 2:
Mailing Address - City:RUSTBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24588-3574
Mailing Address - Country:US
Mailing Address - Phone:434-821-2114
Mailing Address - Fax:434-821-4734
Practice Address - Street 1:565 LYNBROOK RD
Practice Address - Street 2:
Practice Address - City:RUSTBURG
Practice Address - State:VA
Practice Address - Zip Code:24588-3574
Practice Address - Country:US
Practice Address - Phone:434-821-2114
Practice Address - Fax:434-821-4734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-16
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0157008159Medicaid