=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760348510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE MOON BEHAVIORAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2025
-----------------------------------------------------
Last Update Date | 12/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6870 KY-899
-----------------------------------------------------
City | PIPPA PASSES
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-922-4644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 280
-----------------------------------------------------
City | PEWEE VALLEY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40056-0280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATION
-----------------------------------------------------
Name | KAYLA PARSONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 606-922-4644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------