Provider Demographics
NPI:1912798174
Name:BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC
Entity type:Organization
Organization Name:BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSIANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PROCENKO
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-C
Authorized Official - Phone:320-310-8895
Mailing Address - Street 1:740 KIMBERLY APT 302
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-2963
Mailing Address - Country:US
Mailing Address - Phone:320-310-8895
Mailing Address - Fax:
Practice Address - Street 1:2222 W GRAND RIVER AVE STE A
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1604
Practice Address - Country:US
Practice Address - Phone:248-266-0625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-15
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)