=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790401735
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOONSTONE PSYCHOLOGICAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 11/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 E GREYHOUND PASS STE 18-128
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46033-7787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-564-9797
-----------------------------------------------------
Fax | 877-401-3034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1950 E GREYHOUND PASS STE 18-128
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46033-7787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-564-9797
-----------------------------------------------------
Fax | 877-401-3034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | DR. COLIN RAK-DIETZ
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 317-564-9797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------