Healthcare Provider Details

I. General information

NPI: 1982142675
Provider Name (Legal Business Name): SUN MOON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 HENRY AVE THREE FALL CENTER, SUITE 302
PHILADELPHIA PA
19129-1121
US

IV. Provider business mailing address

3300 HENRY AVE THREE FALL CENTER, SUITE 302
PHILADELPHIA PA
19129-1121
US

V. Phone/Fax

Practice location:
  • Phone: 215-924-0684
  • Fax: 215-924-3805
Mailing address:
  • Phone: 215-924-0684
  • Fax: 215-924-3805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPS015809
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS015809
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPS015809
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License NumberPS015809
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: