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General NPI Number Information
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NPI Number | 1124422647
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Entity Type | Organization
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Legal Business Name | MOONFLOWER & MORNING GLORY, INC
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Dates
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Enumeration Date | 10/13/2014
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Last Update Date | 11/17/2014
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Provider Practice Location Address
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Address Line | 1609 N FEDERAL HWY
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City | LAKE WORTH
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State | FL
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Zip | 33460-6644
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Country | US
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Telephone | 561-582-3459
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Fax |
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Provider Business Mailing Address
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Address Line | 1609 N FEDERAL HWY
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City | LAKE WORTH
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State | FL
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Zip | 33460-6644
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Country | US
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Telephone | 561-582-3459
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SUE BABCOCK
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Credential | PSY.D.
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Telephone | 651-295-8333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY8414
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License Number State | FL
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