Provider Demographics
NPI:1386252237
Name:MOON, MICHELLE JINSUN
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JINSUN
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 HURON ST APT 433
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80202-1052
Mailing Address - Country:US
Mailing Address - Phone:720-656-0563
Mailing Address - Fax:
Practice Address - Street 1:2975 HURON ST APT 433
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80202-1052
Practice Address - Country:US
Practice Address - Phone:720-656-0563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1303140Medicaid