Healthcare Provider Details

I. General information

NPI: 1427902873
Provider Name (Legal Business Name): DR MOON PSYCHOLOGY CENTER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2026
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9663 TIERRA GRANDE ST STE 104
SAN DIEGO CA
92126-4569
US

IV. Provider business mailing address

9663 TIERRA GRANDE ST STE 104
SAN DIEGO CA
92126-4569
US

V. Phone/Fax

Practice location:
  • Phone: 619-736-0333
  • Fax: 619-365-5994
Mailing address:
  • Phone: 619-736-0333
  • Fax: 619-365-5994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JEONGMI MOON
Title or Position: PRESIDENT
Credential: PH.D
Phone: 619-736-0333