Provider Demographics
NPI:1679395362
Name:MOONBRIDGE THERAPY LLC
Entity type:Organization
Organization Name:MOONBRIDGE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:KAARE
Authorized Official - Last Name:KLITGAARD
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:801-251-6431
Mailing Address - Street 1:PO BOX 540032
Mailing Address - Street 2:
Mailing Address - City:NORTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84054-0032
Mailing Address - Country:US
Mailing Address - Phone:801-251-6431
Mailing Address - Fax:
Practice Address - Street 1:503 W 2600 S SUITE 200, A
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-251-6431
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-25
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty