Organization
BLUE MOON OF COLORADO LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MELANIE DONOHUE (AUTHORIZED OFFICIAL)
(702) 403-0438
Entity
Organization
Contact information
Practice address
10204 BODE ST STE B, PLAINFIELD, IL 60585-9813
(855) 241-7160
(954) 324-8354
Mailing address
10204 BODE ST STE B, PLAINFIELD, IL 60585-9813
(855) 241-7160
(954) 324-8354
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Enumeration date
08/08/2017
Last updated
09/20/2019
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