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General NPI Number Information
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NPI Number | 1053125658
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Entity Type | Organization
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Legal Business Name | BUNY MOON THERAPY, PLLCS
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Dates
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Enumeration Date | 02/04/2025
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Last Update Date | 02/04/2025
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Provider Practice Location Address
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Address Line | 275 E SOUTH TEMPLE STE 350
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City | SALT LAKE CITY
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State | UT
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Zip | 84111-1272
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Country | US
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Telephone | 512-767-0685
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Fax |
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Provider Business Mailing Address
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Address Line | 2205 N PINECREST CANYON RD
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City | SALT LAKE CITY
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State | UT
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Zip | 84108-1853
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Country | US
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Telephone | 512-767-0685
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | IVY ROSE MARSH
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Credential | LCSW
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Telephone | 512-767-0685
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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