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General NPI Number Information
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NPI Number | 1912798174
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Entity Type | Organization
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Legal Business Name | BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC
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Dates
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Enumeration Date | 05/15/2025
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | 2222 W GRAND RIVER AVE STE A
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City | OKEMOS
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State | MI
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Zip | 48864-1604
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Country | US
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Telephone | 248-266-0625
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Fax |
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Provider Business Mailing Address
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Address Line | 740 KIMBERLY APT 302
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City | LAKE ORION
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State | MI
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Zip | 48362-2963
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Country | US
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Telephone | 320-310-8895
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | CASSIANN M PROCENKO
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Credential | LMSW-C
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Telephone | 320-310-8895
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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