Healthcare Provider Details

I. General information

NPI: 1730143553
Provider Name (Legal Business Name): MOON RIVER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 OAK TRAIL DR
MARIETTA GA
30062-7502
US

IV. Provider business mailing address

790 OAK TRAIL DR
MARIETTA GA
30062-7502
US

V. Phone/Fax

Practice location:
  • Phone: 770-977-6866
  • Fax: 770-977-6887
Mailing address:
  • Phone: 770-212-2170
  • Fax: 770-783-8639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003833
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberOT 004293
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberGAOT001717
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP003992
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP005806
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP006528
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP 06551
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP 006556
License Number StateGA
# 10
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: LAURA DESANTIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-212-2170