Provider Demographics
NPI:1962569186
Name:MOON, DENNISE (PSYD)
Entity type:Individual
Prefix:
First Name:DENNISE
Middle Name:
Last Name:MOON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 HEGENBERGER RD
Mailing Address - Street 2:C/O LIGHTHOUSE COMMUNITY CHARTER SCHOOL
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-1418
Mailing Address - Country:US
Mailing Address - Phone:510-863-8035
Mailing Address - Fax:
Practice Address - Street 1:444 HEGENBERGER RD
Practice Address - Street 2:C/O LIGHTHOUSE COMMUNITY CHARTER SCHOOL
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94621-1418
Practice Address - Country:US
Practice Address - Phone:510-589-8367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26444103TC0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical