Organization
BLUE MOON SENIOR COUNSELING OF ILLINOIS LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MELANIE DONOHUE LCSW (AUTHORIZED OFFICIAL)
(855) 241-7160
Entity
Organization
Contact information
Practice address
10204 BODE ST STE B, PLAINFIELD, IL 60585-9813
(855) 241-7160
(954) 465-5142
Mailing address
10204 BODE ST STE B, PLAINFIELD, IL 60585-9813
(855) 241-7160
(954) 324-8354
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
IL7187
MEDICARE PTAN
IL
Enumeration date
02/03/2012
Last updated
09/20/2019
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