Blue Moon Therapy LLC

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

BLUE MOON THERAPY LLC

Practice address

400 N Woodlawn
Suite 100
Wichita, KS 67216-1360

Phone

(316) 652-2580

NPI assigned

Sep 12, 2018

Last updated

Sep 12, 2018By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Shannon D. Goodwin, LSCSWNPI 1386782746

Title

Clinical Social Worker

Phone

(316) 249-4447

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in KS

Enrollment records 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Shannon Dannielle Goodwin, LMSW, AAPS

  • Clinical Social Worker
  • Wichita, KS
  • NPI 1386782746
  Medicare reassignment NPD Authorized official

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

{
    "created_epoch": "1536710400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1536710400000",
    "number": "1205319472",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1215 E JUMP ST",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672161360",
            "telephone_number": "316-249-4447"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "400 N WOODLAWN",
            "address_2": "SUITE 100",
            "city": "WICHITA",
            "state": "KS",
            "postal_code": "672161360",
            "telephone_number": "316-652-2580"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLUE MOON THERAPY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-09-12",
        "last_updated": "2018-09-12",
        "status": "A",
        "authorized_official_last_name": "GOODWIN",
        "authorized_official_first_name": "SHANNON",
        "authorized_official_middle_name": "D.",
        "authorized_official_title_or_position": "CLINICAL SOCIAL WORKER",
        "authorized_official_telephone_number": "316-249-4447",
        "authorized_official_credential": "LSCSW"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Clinic/Center (Including Community Mental Health Center) in Wichita, KS
• Providers in Wichita, KS by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Kansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 12, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.