Basic Information
| Provider Information | |||||||||
| NPI: | 1982142675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOON | ||||||||
| FirstName: | SUN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 HENRY AVE | ||||||||
| Address2: | THREE FALL CENTER, SUITE 302 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159240684 | ||||||||
| FaxNumber: | 2159243805 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 HENRY AVE | ||||||||
| Address2: | THREE FALL CENTER, SUITE 302 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159240684 | ||||||||
| FaxNumber: | 2159243805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2017 | ||||||||
| LastUpdateDate: | 02/02/2017 | ||||||||
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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 | 103TB0200X | PS015809 | PA | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC0700X | PS015809 | PA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC2200X | PS015809 | PA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TM1800X | PS015809 | PA | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
No ID Information.