MEDICARE: EMMA ISABEL MOON MS, BCBA

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	174400000X	Specialist
2	103K00000X	Behavior Analyst	1-21-51967	CA
3	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1093175291
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA ISABEL MOON MS, BCBA

Provider Business Mailing Address
First Line	:	8032 E BYNUM ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-3231
Country	:	US
Telephone Number	:	720-670-8357
Fax Number	:

Provider Business Practice Location Address
First Line	:	8032 E BYNUM ST APT 303
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90808-3231
Country	:	US
Telephone Number	:	720-670-8357
Fax Number	:

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

Provider Enumeration Date	:	03/01/2016
Last Update Date	:	08/03/2021

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