Healthcare Provider Details

I. General information

NPI: 1720713100
Provider Name (Legal Business Name): MOONLIGHT MEADOWS COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 N 2858 E
ROBERTS ID
83444-5070
US

IV. Provider business mailing address

639 N 2858 E
ROBERTS ID
83444-5070
US

V. Phone/Fax

Practice location:
  • Phone: 208-585-8086
  • Fax:
Mailing address:
  • Phone: 208-585-8086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACIE S KARLINSEY
Title or Position: OWNER/THERAPIST
Credential: LCSW
Phone: 208-585-8086