Waning Moon LLC

NPI #1467144675 in O Fallon, Illinois

Provider Information

NPI Number: 1467144675
Entity Type: Organization
Organization Name: Waning Moon LLC
Primary Specialty: Clinic/Center - Mental Health (Including Community Mental Health Center)
Enumeration Date: May 25, 2023
Last Updated: May 25, 2023

Practice Location

Address: 502 W STATE ST
City: O Fallon
State: Illinois
ZIP Code: 62269-1913
Phone: (217) 891-4931

Authorized Official

Name: SHELBY REECE, LCPC
Title: OWNER
Phone: (217) 891-4931

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Clinic/Center - Adult Mental Health — Adult Mental Health	261QM0850X
Clinic/Center - Adolescent and Children Mental Health — Adolescent and Children Mental Health	261QM0855X
Clinic/Center - Mental Health (Including Community Mental Health Center) — Mental Health (Including Community Mental Health Center)	261QM0801X	Primary

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