Healthcare Provider Details

I. General information

NPI: 1922567775
Provider Name (Legal Business Name): RISING MOON THERAPEUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 E BROADWAY BLVD STE 223
TUCSON AZ
85711-3558
US

IV. Provider business mailing address

4560 E BROADWAY BLVD STE 223
TUCSON AZ
85711-3558
US

V. Phone/Fax

Practice location:
  • Phone: 520-528-6534
  • Fax:
Mailing address:
  • Phone: 520-528-6534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JENNA TESO
Title or Position: PRESIDENT
Credential:
Phone: 520-528-6534