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Organization
MOON RIVER, LLC
Active
Organization
MOON RIVER, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA DESANTIS (OFFICE MANAGER)
(770) 212-2170
Entity
Organization
Contact information
Practice address
790 OAK TRAIL DR, MARIETTA, GA 30062-7502
(770) 977-6866
(770) 977-6887
Mailing address
790 OAK TRAIL DR, MARIETTA, GA 30062-7502
(770) 212-2170
(770) 783-8639
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
Primary
—
—
103T00000X
Psychologist
—
—
225100000X
Physical Therapist
PT003833
GA
225XP0200X
Pediatric Occupational Therapist
GAOT001717
GA
225XP0200X
Pediatric Occupational Therapist
OT 004293
GA
235Z00000X
Speech-Language Pathologist
SLP 006556
GA
235Z00000X
Speech-Language Pathologist
SLP 06551
GA
235Z00000X
Speech-Language Pathologist
SLP003992
GA
235Z00000X
Speech-Language Pathologist
SLP005806
GA
235Z00000X
Speech-Language Pathologist
SLP006528
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000753563E
—
GA
05
—
000860736B
—
GA
05
—
000970835A
—
GA
05
—
146855825A
—
GA
05
—
188883028B
—
GA
05
—
191707573A
—
GA
05
—
240960806A
—
GA
05
—
315889908A
—
GA
05
—
317872221A
—
GA
05
—
339518223A
—
GA
05
—
426315361A
—
GA
05
—
461168837A
—
GA
05
—
481436178B
—
GA
05
—
503885675B
—
GA
05
—
516643175A
—
GA
05
—
761415888A
—
GA
05
—
765677599A
—
GA
05
—
814363142A
—
GA
05
—
850524466A
—
GA
05
—
986209149B
—
GA
Enumeration date
04/17/2006
Last updated
02/18/2025
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