Provider Demographics
NPI:1477386043
Name:MOON, DANYEL LACHEON (EDS)
Entity type:Individual
Prefix:MRS
First Name:DANYEL
Middle Name:LACHEON
Last Name:MOON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13059 N COUNTY ROAD 200 W
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-6875
Mailing Address - Country:US
Mailing Address - Phone:812-605-2911
Mailing Address - Fax:
Practice Address - Street 1:1329 2ND ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:IN
Practice Address - Zip Code:47932-1009
Practice Address - Country:US
Practice Address - Phone:765-231-3183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-20
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10320048103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool