Provider Demographics
NPI:1174231807
Name:MOON, HALEY RAYNE
Entity type:Individual
Prefix:MRS
First Name:HALEY
Middle Name:RAYNE
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 1:209 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-8525
Mailing Address - Country:US
Mailing Address - Phone:504-610-1623
Mailing Address - Fax:
Practice Address - Street 1:2000 COVINGTON CTR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-2979
Practice Address - Country:US
Practice Address - Phone:985-237-1921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LABACB804628106S00000X
LAL886103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician