Healthcare Provider Details

I. General information

NPI: 1124890165
Provider Name (Legal Business Name): NEW MOON ECOTHERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 15TH AVE S STE 102
SEATTLE WA
98108-1874
US

IV. Provider business mailing address

4501 15TH AVE S STE 102
SEATTLE WA
98108-1874
US

V. Phone/Fax

Practice location:
  • Phone: 206-552-8857
  • Fax:
Mailing address:
  • Phone: 206-552-8857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ARI BONAGOFSKI
Title or Position: OWNER
Credential:
Phone: 206-552-8857