=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083561161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOON MAMA THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/16/2026
-----------------------------------------------------
Last Update Date | 03/16/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18204 A ST S
-----------------------------------------------------
City | SPANAWAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98387-8327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-545-3458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18204 A ST S
-----------------------------------------------------
City | SPANAWAY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98387-8327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-545-3458
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST/OWNER
-----------------------------------------------------
Name | ASHLEY MARTINEZ
-----------------------------------------------------
Credential | LICSW, PMH-C
-----------------------------------------------------
Telephone | 360-545-3458
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------