Basic Information
| Provider Information | |||||||||
| NPI: | 1891764940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 73 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NEW CONCORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437621237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408264353 | ||||||||
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| Practice Location | |||||||||
| Address1: | 710 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COSHOCTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 438121615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404549766 | ||||||||
| FaxNumber: | 7405886452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S0010829 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 318201 | 01 | OH | MOUNT CARMEL PIN | OTHER |