Healthcare Provider Details

I. General information

NPI: 1124759006
Provider Name (Legal Business Name): 3 MOON THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10913 APACHE AVE NE
ALBUQUERQUE NM
87112-3203
US

IV. Provider business mailing address

PO BOX 53104
ALBUQUERQUE NM
87153-3104
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-6005
  • Fax:
Mailing address:
  • Phone: 505-234-6005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARY DUNCAN
Title or Position: THERAPIST
Credential: LCSW
Phone: 505-234-6005