=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740519875
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESCENT MOON COUNSELING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2009
-----------------------------------------------------
Last Update Date | 12/21/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 221 ORANGE ST
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27536-4234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-431-0075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1410 N MANGUM ST
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27701-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-431-0075
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SANDI GRAY-TERRY
-----------------------------------------------------
Credential | MSW, LCSW
-----------------------------------------------------
Telephone | 252-431-0075
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | C002534
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------