Healthcare Provider Details

I. General information

NPI: 1780345348
Provider Name (Legal Business Name): THERAPY BY MOONLIGHT, INC.; IMARI CHILDS, LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 ORANGE AVE
LONG BEACH CA
90807-3717
US

IV. Provider business mailing address

6078 KINGWOOD CIR APT 76
ROCKLIN CA
95677-3473
US

V. Phone/Fax

Practice location:
  • Phone: 310-362-4047
  • Fax:
Mailing address:
  • Phone: 415-637-0232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: IMARI CHILDS
Title or Position: CEO
Credential: LCSW
Phone: 415-637-0232