Healthcare Provider Details

I. General information

NPI: 1336857671
Provider Name (Legal Business Name): RUBY MOON EDS, NCSP, LMHCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY RUTH SQUEZELLO EDS, NCSP, LMHCA

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 S HOWARD ST STE 216
SPOKANE WA
99201-3816
US

IV. Provider business mailing address

522 W RIVERSIDE AVE STE N
SPOKANE WA
99201-0580
US

V. Phone/Fax

Practice location:
  • Phone: 509-720-8052
  • Fax:
Mailing address:
  • Phone: 509-720-8052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number499286C
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61324957
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: