Healthcare Provider Details

I. General information

NPI: 1144182650
Provider Name (Legal Business Name): SUMMER MOON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 RIDLEY AVE
LAGRANGE GA
30240-2231
US

IV. Provider business mailing address

121 CRESTVIEW RD
WEST POINT GA
31833-5221
US

V. Phone/Fax

Practice location:
  • Phone: 706-756-1970
  • Fax:
Mailing address:
  • Phone: 706-585-0204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014910
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: