Healthcare Provider Details

I. General information

NPI: 1922079581
Provider Name (Legal Business Name): TEENA MOY PHD LP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 COMO AVE MAIL STOP 31100A
ST PAUL MN
55108-1460
US

IV. Provider business mailing address

8100 34TH AVE S
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-641-6200
  • Fax: 651-641-6205
Mailing address:
  • Phone: 952-883-5463
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0954
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: