# BLUE MOON BEHAVIORAL HEALTH, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1023841061
- **Authorized official:** SHINEKA LATOYA MACK PMHNP-BC (OWNER)
- **Authorized official phone:** (704) 258-6720

## Contact information

- **Practice address:** 199 E MONTGOMERY AVE STE 100, ROCKVILLE, MD 20850-2361
- **Practice address phone:** (301) 719-2913
- **Practice address fax:** (301) 867-5278
- **Mailing address:** 9302 WOODEN RD, RALEIGH, NC 27617-8214
- **Mailing address phone:** (704) 258-6720

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 08/23/2024
- **Last updated:** 08/23/2024