Provider Demographics
NPI:1649044058
Name:MOONRISE THERAPY PLLC
Entity type:Organization
Organization Name:MOONRISE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-708-5405
Mailing Address - Street 1:708 CHURCH ST STE 251
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-3840
Mailing Address - Country:US
Mailing Address - Phone:773-517-8105
Mailing Address - Fax:
Practice Address - Street 1:708 CHURCH ST STE 251
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-3840
Practice Address - Country:US
Practice Address - Phone:773-517-8105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty