Provider Demographics
NPI:1245998467
Name:LUNAR PHASE RESTORATIVE HEALTH, LLC
Entity type:Organization
Organization Name:LUNAR PHASE RESTORATIVE HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:SAGE
Authorized Official - Last Name:BELKNAP-GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:859-200-9858
Mailing Address - Street 1:216 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-1444
Mailing Address - Country:US
Mailing Address - Phone:859-544-2047
Mailing Address - Fax:
Practice Address - Street 1:216 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-1444
Practice Address - Country:US
Practice Address - Phone:859-544-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-05
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)