Provider Demographics
NPI:1174324743
Name:MOON, WENDOLYN (LCDC)
Entity type:Individual
Prefix:
First Name:WENDOLYN
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1278 FM 1798 E
Mailing Address - Street 2:
Mailing Address - City:MT ENTERPRISE
Mailing Address - State:TX
Mailing Address - Zip Code:75681-3091
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2323 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-7747
Practice Address - Country:US
Practice Address - Phone:903-535-7341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14225101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)