Provider Demographics
NPI:1740519875
Name:CRESCENT MOON COUNSELING, INC.
Entity type:Organization
Organization Name:CRESCENT MOON COUNSELING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY-TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:252-431-0075
Mailing Address - Street 1:1410 N MANGUM ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-1311
Mailing Address - Country:US
Mailing Address - Phone:252-431-0075
Mailing Address - Fax:
Practice Address - Street 1:221 ORANGE ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-4234
Practice Address - Country:US
Practice Address - Phone:252-431-0075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0025341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC36593OtherBCBS-NC
NC6003804Medicaid