=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750205654
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLAYTON MOON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2026
-----------------------------------------------------
Last Update Date | 08/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4805 GOLDEN FOOTHILL PKWY
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-9651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-644-2412
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4805 GOLDEN FOOTHILL PKWY
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-9651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-760-9847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 132860
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------