Healthcare Provider Details

I. General information

NPI: 1629593967
Provider Name (Legal Business Name): BLUE MOON OF COLORADO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2017
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10204 BODE ST STE B
PLAINFIELD IL
60585-9813
US

IV. Provider business mailing address

10204 BODE ST STE B
PLAINFIELD IL
60585-9813
US

V. Phone/Fax

Practice location:
  • Phone: 855-241-7160
  • Fax: 954-324-8354
Mailing address:
  • Phone: 855-241-7160
  • Fax: 954-324-8354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MELANIE DONOHUE
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 702-403-0438