Provider Demographics
NPI:1063392934
Name:CRESCENT MOON PSYCHIATRY LLC
Entity type:Organization
Organization Name:CRESCENT MOON PSYCHIATRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:970-427-2820
Mailing Address - Street 1:1302 S SHIELDS ST STE A1-2
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-4801
Mailing Address - Country:US
Mailing Address - Phone:970-427-2820
Mailing Address - Fax:970-585-8169
Practice Address - Street 1:1302 S SHIELDS ST STE A1-2
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-4801
Practice Address - Country:US
Practice Address - Phone:970-427-2820
Practice Address - Fax:970-585-8169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty