MEDICARE: BLUE MOON THERAPY, PLLC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1972255560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE MOON THERAPY, PLLC

Provider Business Mailing Address
First Line	:	8515 SPOTSLYVANIA LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77083-6437
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23144 CINCO RANCH BLVD # B-1105
Second Line	:
City	:	KATY
State	:	TX
Zip	:	77494-2894
Country	:	US
Telephone Number	:	832-535-2616
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	ANGELA BAILEY
Credential	:	LCSW
Telephone Number	:	832-600-2493

Provider Enumeration Date	:	01/25/2022
Last Update Date	:	10/02/2024

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