Provider Demographics
NPI:1104826510
Name:PEDIATRIC & FAMILY PSYCHOLOGY CENTER PA
Entity Type:Organization
Organization Name:PEDIATRIC & FAMILY PSYCHOLOGY CENTER PA
Other - Org Name:CH MOORE PHD DBA PEDIATRIC & FAMILY PSYCHOLOGY CENTER PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:C
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-771-4766
Mailing Address - Street 1:2440 N CHARLES STREET
Mailing Address - Street 2:SUITE 236
Mailing Address - City:NORTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-3050
Mailing Address - Country:US
Mailing Address - Phone:651-771-4766
Mailing Address - Fax:651-771-4784
Practice Address - Street 1:2440 N CHARLES STREET
Practice Address - Street 2:SUITE 236
Practice Address - City:NORTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3050
Practice Address - Country:US
Practice Address - Phone:651-771-4766
Practice Address - Fax:651-771-4784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2246103T00000X
WAPY00000625103T00000X
CO440103T00000X
MN1106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6049644OtherSTATE OF MN
MNHP19293OtherHEALTH PART NERS
WI39036800Medicaid
MN104097OtherUCARE
MN212T8PEOtherBC/BS/BT