Provider Demographics
NPI:1548539042
Name:MOON, SOO Y (MA, LMFT)
Entity type:Individual
Prefix:
First Name:SOO
Middle Name:Y
Last Name:MOON
Suffix:
Gender:F
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1056 CENTERVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:VADNAIS HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55127-6360
Mailing Address - Country:US
Mailing Address - Phone:651-604-8116
Mailing Address - Fax:
Practice Address - Street 1:1056 CENTERVILLE CIR
Practice Address - Street 2:
Practice Address - City:VADNAIS HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55127-6360
Practice Address - Country:US
Practice Address - Phone:651-604-7771
Practice Address - Fax:651-426-8116
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2209106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist