MEDICARE: RITA LACE MOON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	56568	TX

General Provider Information

NPI Number	:	1063896488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RITA LACE MOON

Provider Business Mailing Address
First Line	:	13740 RESEARCH BLVD STE B2
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-1859
Country	:	US
Telephone Number	:	512-565-4433
Fax Number	:	512-792-4831

Provider Business Practice Location Address
First Line	:	13740 RESEARCH BLVD STE B2
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78750-1859
Country	:	US
Telephone Number	:	512-565-4433
Fax Number	:	512-792-4831

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	02/24/2021

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Directions to “ RITA LACE MOON ” Practice Location

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