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General NPI Number Information
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NPI Number | 1104826510
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Entity Type | Organization
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Legal Business Name | PEDIATRIC & FAMILY PSYCHOLOGY CENTER PA
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Dates
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Enumeration Date | 07/28/2005
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 2440 N CHARLES STREET SUITE 236
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City | NORTH SAINT PAUL
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State | MN
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Zip | 55109-3050
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Country | US
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Telephone | 651-771-4766
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Fax | 651-771-4784
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Provider Business Mailing Address
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Address Line | 2440 N CHARLES STREET SUITE 236
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City | NORTH SAINT PAUL
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State | MN
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Zip | 55109-3050
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Country | US
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Telephone | 651-771-4766
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Fax | 651-771-4784
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Authorized Official
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Title or Position | OWNER
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Name | DR. C L MOORE
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Credential | PHD
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Telephone | 651-771-4766
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY00000625
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP2246
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 440
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License Number State | CO
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Taxonomy #4
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 1
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License Number State | MN
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