| Blue Moon Therapy Llc | |
|
400 N Woodlawn Suite 100 Wichita KS 67216-1360 | |
| (316) 652-2580 | |
| Not Available |
| Full Name | Blue Moon Therapy Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 400 N Woodlawn, Wichita, Kansas |
| Authorized Official Name and Position | Shannon D. Goodwin (CLINICAL SOCIAL WORKER) |
| Authorized Official Contact | 3162494447 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Blue Moon Therapy Llc 1215 E Jump St Wichita KS 67216-1360 Ph: (316) 249-4447 | Blue Moon Therapy Llc 400 N Woodlawn Suite 100 Wichita KS 67216-1360 Ph: (316) 652-2580 |
| NPI Number | 1205319472 |
|---|---|
| Provider Enumeration Date | 09/12/2018 |
| Last Update Date | 09/12/2018 |
| Medicare PECOS PAC ID | 1052738770 |
|---|---|
| Medicare Enrollment ID | O20200826002763 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1205319472 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Shannon D Goodwin |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1386782746 PECOS PAC ID: 3971750548 Enrollment ID: I20120904000758 |
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