Healthcare Provider Details

I. General information

NPI: 1861149510
Provider Name (Legal Business Name): TO THE MOON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2022
Last Update Date: 12/10/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10307 PEBBLEBROOK PL
RICHMOND VA
23238-6807
US

IV. Provider business mailing address

14497 POTOMAC MILLS RD # 1013
WOODBRIDGE VA
22192-6807
US

V. Phone/Fax

Practice location:
  • Phone: 804-728-8882
  • Fax:
Mailing address:
  • Phone: 804-728-8882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: LIZNA KHIMANI
Title or Position: BCBA
Credential: MA
Phone: 804-728-8827