Provider Demographics
NPI:1952123861
Name:FULL MOON WELLNESS AND CONSULTING, LLC
Entity type:Organization
Organization Name:FULL MOON WELLNESS AND CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGGASON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:720-250-7911
Mailing Address - Street 1:7155 SW VARNS ST STE 211
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8175
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7155 SW VARNS ST STE 215
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8175
Practice Address - Country:US
Practice Address - Phone:503-894-7144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty