Healthcare Provider Details

I. General information

NPI: 1942019757
Provider Name (Legal Business Name): CYNTHIA RAE MOON MA, LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 LANCASHIRE DR SE
GRAND RAPIDS MI
49508-2534
US

IV. Provider business mailing address

1515 LANCASHIRE DR SE
GRAND RAPIDS MI
49508-2534
US

V. Phone/Fax

Practice location:
  • Phone: 269-788-2304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451015035
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: