Provider Demographics
NPI:1801169347
Name:RICHELLE MOEN, PHD LLC
Entity type:Organization
Organization Name:RICHELLE MOEN, PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHELLE
Authorized Official - Middle Name:NAOMI
Authorized Official - Last Name:MOEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:612-743-7788
Mailing Address - Street 1:4826 CHICAGO AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4826 CHICAGO AVE STE 207
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-1063
Practice Address - Country:US
Practice Address - Phone:612-743-7788
Practice Address - Fax:612-824-7341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2440251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health