Blue Moon Behavioral Health, PLLC

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

Legal business name

BLUE MOON BEHAVIORAL HEALTH, PLLC

Practice address

199 E Montgomery Ave Ste 100
Rockville, MD 20850-2361

Phone

(301) 719-2913

Fax

(301) 867-5278

NPI assigned

Aug 23, 2024

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Shineka Latoya Mack, PMHNP-BCNPI 1790370047

Title

Owner

Phone

(704) 258-6720

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Shineka Latoya Mack, PMHNP

  • Psychiatric/Mental Health Nurse Practitioner
  • Raleigh, NC
  • NPI 1790370047
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1724371200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1724371200000",
    "number": "1023841061",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9302 WOODEN RD",
            "city": "RALEIGH",
            "state": "NC",
            "postal_code": "276178214",
            "telephone_number": "704-258-6720"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "199 E MONTGOMERY AVE STE 100",
            "city": "ROCKVILLE",
            "state": "MD",
            "postal_code": "208502361",
            "telephone_number": "301-719-2913",
            "fax_number": "301-867-5278"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE MOON BEHAVIORAL HEALTH, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-08-23",
        "last_updated": "2024-08-23",
        "certification_date": "2024-08-23",
        "status": "A",
        "authorized_official_last_name": "MACK",
        "authorized_official_first_name": "SHINEKA",
        "authorized_official_middle_name": "LATOYA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "704-258-6720",
        "authorized_official_credential": "PMHNP-BC"
    },
    "taxonomies": [
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Psychiatric/Mental Health Nurse Practitioner in Rockville, MD
• Providers in Rockville, MD by specialty
• Psychiatric/Mental Health Nurse Practitioner in Maryland

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 23, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.