Healthcare Provider Details

I. General information

NPI: 1952123861
Provider Name (Legal Business Name): FULL MOON WELLNESS AND CONSULTING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7155 SW VARNS ST STE 215
PORTLAND OR
97223-8175
US

IV. Provider business mailing address

7155 SW VARNS ST STE 215
PORTLAND OR
97223-8175
US

V. Phone/Fax

Practice location:
  • Phone: 503-894-7144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE HIGGASON
Title or Position: OWNER/LCSW
Credential: LCSW
Phone: 720-250-7911