| Blue Moon Of Colorado Llc | |
|
10204 Bode St Ste B Plainfield IL 60585-9813 | |
| (855) 241-7160 | |
| (954) 324-8354 |
| Full Name | Blue Moon Of Colorado Llc |
|---|---|
| Speciality | Social Worker |
| Location | 10204 Bode St Ste B, Plainfield, Illinois |
| Authorized Official Name and Position | Melanie Donohue (AUTHORIZED OFFICIAL) |
| Authorized Official Contact | 7024030438 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Blue Moon Of Colorado Llc 10204 Bode St Ste B Plainfield IL 60585-9813 Ph: (855) 241-7160 | Blue Moon Of Colorado Llc 10204 Bode St Ste B Plainfield IL 60585-9813 Ph: (855) 241-7160 |
| NPI Number | 1629593967 |
|---|---|
| Provider Enumeration Date | 08/08/2017 |
| Last Update Date | 09/20/2019 |
| Medicare PECOS PAC ID | 5698034791 |
|---|---|
| Medicare Enrollment ID | O20180118000946 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629593967 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103T00000X | Psychologist | (* (Not Available)) | Secondary |
| 1041C0700X | Social Worker - Clinical | (* (Not Available)) | Primary |
| Provider Name | Tamera J Ford |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1982955373 PECOS PAC ID: 3274788971 Enrollment ID: I20130304000150 |
| Provider Name | Melissa Anne Hoskins |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1760738777 PECOS PAC ID: 5193098150 Enrollment ID: I20170913002692 |
| Provider Name | Stephen A Valente |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1154841054 PECOS PAC ID: 4183989064 Enrollment ID: I20180523002590 |
| Provider Name | Tonya Junod |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1235149444 PECOS PAC ID: 5092879775 Enrollment ID: I20180910002766 |
| Provider Name | Kimberly Dunn-lipscomb |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1467786434 PECOS PAC ID: 3678727674 Enrollment ID: I20180918003340 |
| Provider Name | Jessica N Huffer |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1871638437 PECOS PAC ID: 6305244146 Enrollment ID: I20211008002654 |
| Provider Name | David Kamis |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1124493648 PECOS PAC ID: 9537543772 Enrollment ID: I20220907001386 |
| Provider Name | Karen Vigeland |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1841938867 PECOS PAC ID: 9436504263 Enrollment ID: I20240307002713 |
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