Provider Demographics
NPI:1053125658
Name:BUNY MOON THERAPY, PLLCS
Entity type:Organization
Organization Name:BUNY MOON THERAPY, PLLCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IVY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:512-767-0685
Mailing Address - Street 1:2205 N PINECREST CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1853
Mailing Address - Country:US
Mailing Address - Phone:512-767-0685
Mailing Address - Fax:
Practice Address - Street 1:275 E SOUTH TEMPLE STE 350
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1272
Practice Address - Country:US
Practice Address - Phone:512-767-0685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty