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NPI Code Detail

MEDICARE: KYLE KATHLEEN MOON

MEDICARE: KYLE KATHLEEN 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
1101YM0800XMental Health Counselor
2101Y00000XCounselor

General Provider Information

NPI Number : 1144766221
Entity Type Code : Individual
Provider Name (Legal Business Name) : KYLE KATHLEEN MOON
Provider Business Mailing Address
First Line : 3415 SE POWELL BLVD
Second Line :
City : PORTLAND
State : OR
Zip : 97202-3371
Country : US
Telephone Number : 503-234-9591
Fax Number :
Provider Business Practice Location Address
First Line : 3601 W 10TH ST
Second Line :
City : THE DALLES
State : OR
Zip : 97058-4377
Country : US
Telephone Number : 503-234-9591
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/12/2017
Last Update Date : 09/15/2023

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