Healthcare Provider Details

I. General information

NPI: 1659204469
Provider Name (Legal Business Name): MOONSHINE RIDGE PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7840 SE 701 RD
COLLINS MO
64738-7129
US

IV. Provider business mailing address

3915 LLOYD ST
KANSAS CITY KS
66103-2828
US

V. Phone/Fax

Practice location:
  • Phone: 620-423-5060
  • Fax:
Mailing address:
  • Phone: 620-423-5060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: TANESA HILL
Title or Position: OWNER
Credential: PSYD
Phone: 620-423-5060