MEDICARE: MOONLIT COUNSELING

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1184478620
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOONLIT COUNSELING

Provider Business Mailing Address
First Line	:	3595 E FOUNTAIN BLVD STE 205
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-7718
Country	:	US
Telephone Number	:	719-623-7190
Fax Number	:	719-399-1669

Provider Business Practice Location Address
First Line	:	3595 E FOUNTAIN BLVD STE 205
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80910-7718
Country	:	US
Telephone Number	:	719-623-7190
Fax Number	:	719-399-1669

Authorized Official
Title or Position	:	OWNER
Name	:	ASHLIE D STAPLES
Credential	:	LPC
Telephone Number	:	719-623-7190

Provider Enumeration Date	:	04/12/2024
Last Update Date	:	04/12/2024

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