Provider Demographics
NPI:1811140866
Name:MOON, GEORGINA RAE
Entity type:Individual
Prefix:
First Name:GEORGINA
Middle Name:RAE
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 KISMET WAY
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2728 KISMET WAY
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-6203
Practice Address - Country:US
Practice Address - Phone:541-606-2788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health