Provider Demographics
NPI:1043307085
Name:MOON, WILLIAM (PHD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:MOON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2348
Mailing Address - Street 2:17A FELTON PLACE
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-1690
Mailing Address - Country:US
Mailing Address - Phone:770-386-8996
Mailing Address - Fax:770-386-8100
Practice Address - Street 1:17 FELTON PL STE A
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2153
Practice Address - Country:US
Practice Address - Phone:770-386-8996
Practice Address - Fax:770-386-8100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001063103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBBDCMedicare ID - Type Unspecified