MEDICARE: BLUE MOON SENIOR COUNSELING, 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
1	251S00000X	Community/Behavioral Health Agency	SW10454	FL

General Provider Information

NPI Number	:	1245588441
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE MOON SENIOR COUNSELING, LLC.

Provider Business Mailing Address
First Line	:	900 NE 18TH AVE APT 1207
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3054
Country	:	US
Telephone Number	:	630-844-7077
Fax Number	:

Provider Business Practice Location Address
First Line	:	900 NE 18TH AVE APT 1207
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33304-3054
Country	:	US
Telephone Number	:	630-844-7077
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MELANIE DONOHUE
Credential	:	LCSW
Telephone Number	:	855-241-7160

Provider Enumeration Date	:	08/17/2012
Last Update Date	:	08/17/2012

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