Healthcare Provider Details

I. General information

NPI: 1295217347
Provider Name (Legal Business Name): LUNA COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WARDER ST STE 165
SPRINGFIELD OH
45504-2500
US

IV. Provider business mailing address

5959 E CASSTOWN CLARK RD
CASSTOWN OH
45312-9746
US

V. Phone/Fax

Practice location:
  • Phone: 937-717-8643
  • Fax:
Mailing address:
  • Phone: 937-717-8643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MS. JORDAN LEA PREBYS
Title or Position: OWNER/LICENSED COUNSELOR
Credential: MA, LPCC, RPT, SP
Phone: 937-717-8643