Healthcare Provider Details

I. General information

NPI: 1902512122
Provider Name (Legal Business Name): MOON FAMILY & BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 CLINT DR STE 200
PICKERINGTON OH
43147-7794
US

IV. Provider business mailing address

161 CLINT DR STE 200
PICKERINGTON OH
43147-7794
US

V. Phone/Fax

Practice location:
  • Phone: 614-705-6161
  • Fax: 614-705-6151
Mailing address:
  • Phone: 614-705-6161
  • Fax: 614-705-6151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN DEAN
Title or Position: ADMIN
Credential:
Phone: 614-706-5206