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General NPI Number Information
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NPI Number | 1730143553
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Entity Type | Organization
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Legal Business Name | MOON RIVER, LLC
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Dates
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Enumeration Date | 04/17/2006
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Last Update Date | 02/18/2025
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Provider Practice Location Address
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Address Line | 790 OAK TRAIL DR
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City | MARIETTA
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State | GA
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Zip | 30062-7502
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Country | US
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Telephone | 770-977-6866
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Fax | 770-977-6887
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Provider Business Mailing Address
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Address Line | 790 OAK TRAIL DR
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City | MARIETTA
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State | GA
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Zip | 30062-7502
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Country | US
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Telephone | 770-212-2170
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Fax | 770-783-8639
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | LAURA DESANTIS
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Credential |
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Telephone | 770-212-2170
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT003833
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | OT 004293
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | GAOT001717
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP003992
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License Number State | GA
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Taxonomy #6
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP005806
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License Number State | GA
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Taxonomy #7
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP006528
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License Number State | GA
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Taxonomy #8
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP 06551
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License Number State | GA
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Taxonomy #9
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | SLP 006556
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License Number State | GA
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Taxonomy #10
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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