MEDICARE: SIERRA 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
1	2355S0801X	Speech-Language Assistant	3330	CA

General Provider Information

NPI Number	:	1235508953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIERRA MOON

Provider Business Mailing Address
First Line	:	16972 HOSKINS LN APT 2
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92649-5000
Country	:	US
Telephone Number	:	760-780-9664
Fax Number	:

Provider Business Practice Location Address
First Line	:	3722 KATELLA AVE STE C
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-3102
Country	:	US
Telephone Number	:	562-270-2970
Fax Number	:

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

Provider Enumeration Date	:	09/23/2015
Last Update Date	:	10/19/2020

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Directions to “ SIERRA MOON ” Practice Location

Language	Start Address	Practice Location

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