Provider Demographics
NPI:1295557213
Name:MOONFLOWER
Entity type:Organization
Organization Name:MOONFLOWER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. DSW LICSW OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MALLORI
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHEIK
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LICSW
Authorized Official - Phone:218-820-1023
Mailing Address - Street 1:5445 CITY HALL ST
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468-2478
Mailing Address - Country:US
Mailing Address - Phone:218-820-1023
Mailing Address - Fax:
Practice Address - Street 1:5445 CITY HALL ST
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56468-2478
Practice Address - Country:US
Practice Address - Phone:218-820-1023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty