Healthcare Provider Details

I. General information

NPI: 1811651938
Provider Name (Legal Business Name): RADIANT MOON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 12/19/2023
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 E SOUTH UNION AVE
MIDVALE UT
84047-2302
US

IV. Provider business mailing address

5622 S WALDEN GLEN DR
SALT LAKE CITY UT
84123-7925
US

V. Phone/Fax

Practice location:
  • Phone: 385-346-0031
  • Fax: 385-446-0973
Mailing address:
  • Phone: 385-346-0031
  • Fax: 385-446-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult 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: MRS. KATHRYN WINGARD
Title or Position: OWNER/CLINICAL DIRECTOR
Credential: LCMHC, ATR-BC
Phone: 385-346-0031