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NPI Code Detail

MEDICARE: MOON RISING LLC

MEDICARE: MOON RISING 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
1106H00000XMarriage & Family Therapist
2101Y00000XCounselor
3103TP2701XGroup Psychotherapy Psychologist
4101YP2500XProfessional Counselor
5101YM0800XMental Health Counselor

General Provider Information

NPI Number : 1205646775
Entity Type Code : Organization
Provider Name (Legal Business Name) : MOON RISING LLC
Provider Business Mailing Address
First Line : 382 NE 191ST ST
Second Line :
City : MIAMI
State : FL
Zip : 33179-3899
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1300 N PALAFOX ST STE 102C
Second Line :
City : PENSACOLA
State : FL
Zip : 32501-2678
Country : US
Telephone Number : 850-270-7295
Fax Number :
Authorized Official
Title or Position : OWNER
Name : VIRGINIA WALLS
Credential :
Telephone Number : 850-270-7295
Provider Enumeration Date : 01/08/2025
Last Update Date : 06/02/2026

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Directions to “MOON RISING LLC ” Practice Location

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