Healthcare Provider Details

I. General information

NPI: 1053097436
Provider Name (Legal Business Name): INGYU MOON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 08/15/2026
Certification Date: 08/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 BEECHWOOD PL
LEONIA NJ
07605-1713
US

IV. Provider business mailing address

318 BEECHWOOD PL
LEONIA NJ
07605-1713
US

V. Phone/Fax

Practice location:
  • Phone: 201-970-4460
  • Fax:
Mailing address:
  • Phone: 201-970-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number097865-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2023010568
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06256200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: