Provider Demographics
NPI:1114175791
Name:PARKSIDE PSYCHOLOGY, INC.
Entity Type:Organization
Organization Name:PARKSIDE PSYCHOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:612-871-4336
Mailing Address - Street 1:2124 DUPONT AVE S
Mailing Address - Street 2:104
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2700
Mailing Address - Country:US
Mailing Address - Phone:612-871-4336
Mailing Address - Fax:612-929-2331
Practice Address - Street 1:2124 DUPONT AVE S
Practice Address - Street 2:104
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2700
Practice Address - Country:US
Practice Address - Phone:612-871-4336
Practice Address - Fax:612-929-2331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1891103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN621853900Medicaid
MN67Q05MOOtherBCBSMN
MN67Q05MOOtherBCBSMN