MEDICARE: MOONSTONE MENTAL HEALTH, LLC

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1073389771
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOONSTONE MENTAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	5745 E OLD FARM CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-1141
Country	:	US
Telephone Number	:	719-659-5329
Fax Number	:

Provider Business Practice Location Address
First Line	:	5745 E OLD FARM CIR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-1141
Country	:	US
Telephone Number	:	719-659-5329
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANTHONY DAEMKE
Credential	:	MA, LMFT
Telephone Number	:	719-659-5329

Provider Enumeration Date	:	12/04/2023
Last Update Date	:	12/15/2023

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