Provider Demographics
NPI:1154160364
Name:CRESCENT MOON AWAKENING
Entity type:Organization
Organization Name:CRESCENT MOON AWAKENING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:HAZEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC
Authorized Official - Phone:479-880-3682
Mailing Address - Street 1:307 JAMES CIR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-5829
Mailing Address - Country:US
Mailing Address - Phone:314-246-0086
Mailing Address - Fax:
Practice Address - Street 1:307 JAMES CIR
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5829
Practice Address - Country:US
Practice Address - Phone:479-880-3682
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-20
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty