Provider Demographics
NPI:1811651938
Name:RADIANT MOON, PLLC
Entity type:Organization
Organization Name:RADIANT MOON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WINGARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC, ATR-BC
Authorized Official - Phone:385-346-0031
Mailing Address - Street 1:5622 S WALDEN GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-7925
Mailing Address - Country:US
Mailing Address - Phone:385-346-0031
Mailing Address - Fax:385-446-0973
Practice Address - Street 1:940 E SOUTH UNION AVE
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2302
Practice Address - Country:US
Practice Address - Phone:385-346-0031
Practice Address - Fax:385-446-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-25
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty