| Parkside Psychology, Inc. | |
|
2124 Dupont Ave S 104 Minneapolis MN 55405-2700 | |
| (612) 871-4336 | |
| (612) 929-2331 |
| Full Name | Parkside Psychology, Inc. |
|---|---|
| Speciality | Psychologist - Clinical |
| Location | 2124 Dupont Ave S, Minneapolis, Minnesota |
| Authorized Official Name and Position | Sally Ruth Moore (PSYCHOLOGIST/OWNER) |
| Authorized Official Contact | 6128714336 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Parkside Psychology, Inc. 2124 Dupont Ave S 104 Minneapolis MN 55405-2700 Ph: (612) 871-4336 | Parkside Psychology, Inc. 2124 Dupont Ave S 104 Minneapolis MN 55405-2700 Ph: (612) 871-4336 |
| NPI Number | 1114175791 |
|---|---|
| Provider Enumeration Date | 09/08/2008 |
| Last Update Date | 09/08/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1114175791 | NPI | - | NPPES |
| 621853900 | Medicaid | MN | |
| 67Q05MO | Other | MN | BCBSMN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TC0700X | Psychologist - Clinical | LP1891 (Minnesota) | Primary |
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