Healthcare Provider Details

I. General information

NPI: 1497292494
Provider Name (Legal Business Name): MOONBEAU COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W MAIN ST
FRANKFORT KY
40601-1895
US

IV. Provider business mailing address

153 PENMOKEN PARK
LEXINGTON KY
40503-1917
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 701-430-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number170684
License Number StateKY

VIII. Authorized Official

Name: KATHRYN LARSON
Title or Position: LICENSED PROFESSIONAL COUNSELOR ASS
Credential:
Phone: 701-430-2121