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General NPI Number Information
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NPI Number | 1073389771
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Entity Type | Organization
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Legal Business Name | MOONSTONE MENTAL HEALTH, LLC
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Dates
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Enumeration Date | 12/04/2023
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Last Update Date | 12/15/2023
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Provider Practice Location Address
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Address Line | 5745 E OLD FARM CIR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80917-1141
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Country | US
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Telephone | 719-659-5329
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Fax |
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Provider Business Mailing Address
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Address Line | 5745 E OLD FARM CIR
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City | COLORADO SPRINGS
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State | CO
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Zip | 80917-1141
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Country | US
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Telephone | 719-659-5329
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANTHONY DAEMKE
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Credential | MA, LMFT
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Telephone | 719-659-5329
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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