Provider Demographics
NPI:1194123208
Name:MOON, DIANA LYNN (MS, LPC)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
Last Name:MOON
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3032
Mailing Address - Country:US
Mailing Address - Phone:217-347-7179
Mailing Address - Fax:217-342-6716
Practice Address - Street 1:1200 N 4TH ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-3032
Practice Address - Country:US
Practice Address - Phone:217-347-7179
Practice Address - Fax:217-342-6716
Is Sole Proprietor?:No
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010412101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional