Organization
WANING MOON LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SHELBY REECE LCPC (OWNER)
(217) 891-4931
Entity
Organization
Contact information
Practice address
502 W STATE ST, O FALLON, IL 62269-1913
(217) 891-4931
Mailing address
201 BLANC LEE DR, BELLEVILLE, IL 62226-1526
(217) 891-4931
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
Other
Enumeration date
05/25/2023
Last updated
05/25/2023
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