MEDICARE: JUDITH K MOON LMSW ACSW LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	6801012981	MI

General Provider Information

NPI Number	:	1114465184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUDITH K MOON LMSW ACSW LLC

Provider Business Mailing Address
First Line	:	37399 GARFIELD RD STE 200
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48036-3672
Country	:	US
Telephone Number	:	586-421-5164
Fax Number	:	586-421-5179

Provider Business Practice Location Address
First Line	:	37399 GARFIELD RD STE 200
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48036-3672
Country	:	US
Telephone Number	:	586-421-5164
Fax Number	:	586-421-5179

Authorized Official
Title or Position	:	OWNER
Name	:	JUDITH MOON
Credential	:
Telephone Number	:	586-421-5164

Provider Enumeration Date	:	02/09/2017
Last Update Date	:	02/09/2017

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