Provider Demographics
NPI:1194450676
Name:PURPLE MOON SERVICE CENTER, LLC
Entity type:Organization
Organization Name:PURPLE MOON SERVICE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR -OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:VALJEANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CASTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, MAC, CAMSII,
Authorized Official - Phone:904-233-1019
Mailing Address - Street 1:931 CASSAT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-4857
Mailing Address - Country:US
Mailing Address - Phone:904-233-1019
Mailing Address - Fax:
Practice Address - Street 1:931 CASSAT AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4857
Practice Address - Country:US
Practice Address - Phone:904-233-1019
Practice Address - Fax:904-369-4666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-19
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty