| Moonlight Psychotherapy And Psychological Services, Llc | |
|
205 5th Ave S Ste 428 La Crosse WI 54601-4059 | |
| (207) 317-0557 | |
| Not Available |
| Full Name | Moonlight Psychotherapy And Psychological Services, Llc |
|---|---|
| Speciality | Psychologist |
| Location | 205 5th Ave S Ste 428, La Crosse, Wisconsin |
| Authorized Official Name and Position | Frederick William Green (OWNER / PSYCHOLOGIST) |
| Authorized Official Contact | 2073170557 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Moonlight Psychotherapy And Psychological Services, Llc 1718 Sunset Dr La Crosse WI 54601-7030 Ph: (207) 317-0557 | Moonlight Psychotherapy And Psychological Services, Llc 205 5th Ave S Ste 428 La Crosse WI 54601-4059 Ph: (207) 317-0557 |
| NPI Number | 1972075661 |
|---|---|
| Provider Enumeration Date | 12/19/2018 |
| Last Update Date | 12/19/2018 |
| Medicare PECOS PAC ID | 2961741418 |
|---|---|
| Medicare Enrollment ID | O20230913002162 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972075661 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | (* (Not Available)) | Primary |
| Provider Name | Frederick William Green |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1629451588 PECOS PAC ID: 4880969294 Enrollment ID: I20210414001112 |
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