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General NPI Number Information
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NPI Number | 1780276451
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Entity Type | Organization
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Legal Business Name | MOONLIGHT MENTAL HEALTH
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Dates
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Enumeration Date | 02/04/2021
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Last Update Date | 02/04/2021
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Provider Practice Location Address
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Address Line | 211 S MAIN
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City | BENTON
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State | AR
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Zip | 72015-4331
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Country | US
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Telephone | 662-727-1053
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Fax | 501-214-6867
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Provider Business Mailing Address
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Address Line | 208 E RICHARDSON PLACE DR
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City | BRYANT
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State | AR
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Zip | 72022-3246
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Country | US
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Telephone | 501-278-1736
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LAUREN JOHNSON
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Credential | LPC-S
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Telephone | 501-278-1736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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