Healthcare Provider Details

I. General information

NPI: 1932977436
Provider Name (Legal Business Name): DR.MOON PSYCHOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2023
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5050 LOTUS ST APT 28
SAN DIEGO CA
92107-1373
US

IV. Provider business mailing address

5050 LOTUS STREET APT 28
SAN DIEGO CA
92107
US

V. Phone/Fax

Practice location:
  • Phone: 619-674-9764
  • Fax:
Mailing address:
  • Phone: 619-674-9764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateNULL
# 14
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 15
Primary TaxonomyN
Taxonomy Code101200000X
TaxonomyDrama Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: JEONGMI MOON
Title or Position: PSYCHOLOGIST
Credential:
Phone: 619-736-0333