BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC – NPI #1912798174
Clinic/Center

BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC is an AHC clinic located in OKEMOS, MI. NPPES has assigned the NPI number 1912798174 to BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC on May 15, 2025. It is a Type-2 NPI, indicating this NPI number is associated with an organization. The primary taxonomy selected by this provider is 261QM0801X from the Health Care Provider Taxonomy code set, which is classified as Clinic/Center, specializing in Mental Health (Including Community Mental Health Center)

Use the NPI data found here to bill health insurance companies, identify providers enrolled in Medicare and Medicaid services or other HIPAA compliant transactions. See the complete NPI profile for BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC below.

NPI Profile for
BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC

NPI Number
1912798174
Enumeration Date

(more than a year ago)
Entity Type
Type-2  Organization
Organization health care providers may have a single employee or thousands of employees. An example is an incorporated individual who is an organization's only employee.
Legal Name
BY MOONLIGHT AND TIDE PSYCHOTHERAPY PLLC
Primary location
2222 W GRAND RIVER AVE STE A
OKEMOS, MI 48864-1604
Phone: (248) 266-0625 Fax:
1 Other location(s):
740 Kimberly Apt 302
Lake Orion, MI 48362-2963
Phone: (248) 266-0625
Mailing address
740 KIMBERLY APT 302
LAKE ORION, MI 48362-2963
Phone: (320) 310-8895 Fax:
Organization Subpart
No
Authorized Official
CASSIANN PROCENKO
CLINICAL DIRECTOR
Phone: (320) 310-8895
Updated
Certification Date
May 15, 2025

Note: NPPES allows providers to attest to the accuracy of their NPI data. When a provider request any change to the NPI record, they will be able to attest to their changed NPI data, resulting in an updated certification date.

Taxonomy Code(s)

A taxonomy code is a code that describes the health care service provider's type, classification, and the area of specialization. The primary specialty for this provider is indicated as (Primary) below.

Taxonomy Classification / Specialization State License
261QM0801X
- Clinic/Center / Mental Health (Including Community Mental Health Center) (Primary)

The taxonomy codes are selected by the provider at the time of NPI registration. Selection of a taxonomy code does not replace any credentialing or validation process that the provider requesting the code should complete.