Provider Demographics
NPI:1235946799
Name:CRESCENT MOON BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:CRESCENT MOON BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAMILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDREN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:816-769-4486
Mailing Address - Street 1:108 S FAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-2919
Mailing Address - Country:US
Mailing Address - Phone:816-769-4486
Mailing Address - Fax:
Practice Address - Street 1:13000 HARBOR CENTER DR STE 142
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2847
Practice Address - Country:US
Practice Address - Phone:816-769-4486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-17
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty