Provider Demographics
NPI:1023841061
Name:BLUE MOON BEHAVIORAL HEALTH, PLLC
Entity type:Organization
Organization Name:BLUE MOON BEHAVIORAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHINEKA
Authorized Official - Middle Name:LATOYA
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:704-258-6720
Mailing Address - Street 1:9302 WOODEN RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-8214
Mailing Address - Country:US
Mailing Address - Phone:704-258-6720
Mailing Address - Fax:
Practice Address - Street 1:199 E MONTGOMERY AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2361
Practice Address - Country:US
Practice Address - Phone:301-719-2913
Practice Address - Fax:301-867-5278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty