Provider Demographics
NPI:1194884841
Name:MOON, KERIANNE MAUCH (LCSW)
Entity type:Individual
Prefix:DR
First Name:KERIANNE
Middle Name:MAUCH
Last Name:MOON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 LITTLE CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:DRIPPING SPRINGS
Mailing Address - State:TX
Mailing Address - Zip Code:78620-2645
Mailing Address - Country:US
Mailing Address - Phone:218-831-0075
Mailing Address - Fax:
Practice Address - Street 1:10011 LITTLE CREEK CIR
Practice Address - Street 2:
Practice Address - City:DRIPPING SPRINGS
Practice Address - State:TX
Practice Address - Zip Code:78620-2645
Practice Address - Country:US
Practice Address - Phone:218-831-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN165921041C0700X
TX603611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113415900Medicaid