MEDICARE: MOON RIVER COUNSELING TX PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1730017625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOON RIVER COUNSELING TX PLLC

Provider Business Mailing Address
First Line	:	102 SUTTLES AVE STE B
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-5015
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	102 SUTTLES AVE STE B
Second Line	:
City	:	SAN MARCOS
State	:	TX
Zip	:	78666-5015
Country	:	US
Telephone Number	:	210-836-8482
Fax Number	:

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	TIFARAH MARIE CANION
Credential	:	LPC
Telephone Number	:	210-836-8482

Provider Enumeration Date	:	05/11/2026
Last Update Date	:	05/11/2026

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