Provider Demographics
NPI:1912280413
Name:SIMPSON, LUNA MONIQUE (CCMA)
Entity Type:Individual
Prefix:MRS
First Name:LUNA
Middle Name:MONIQUE
Last Name:SIMPSON
Suffix:
Gender:F
Credentials:CCMA
Other - Prefix:MS
Other - First Name:LUNA
Other - Middle Name:MONIQUE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RMA
Mailing Address - Street 1:18621 SNOWDEN ST
Mailing Address - Street 2:2B
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1363
Mailing Address - Country:US
Mailing Address - Phone:313-502-1635
Mailing Address - Fax:586-486-5772
Practice Address - Street 1:18621 SNOWDEN ST
Practice Address - Street 2:2B
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1363
Practice Address - Country:US
Practice Address - Phone:313-502-1635
Practice Address - Fax:586-486-5772
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-21
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X, 175F00000X
MI390200000X
MI7471804372500000X
MID8J6B5T7374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No174H00000XOther Service ProvidersHealth Educator
No175F00000XOther Service ProvidersNaturopath
No372500000XNursing Service Related ProvidersChore Provider
No374700000XNursing Service Related ProvidersTechnician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7471804Medicaid