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General NPI Number Information
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NPI Number | 1114175791
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Entity Type | Organization
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Legal Business Name | PARKSIDE PSYCHOLOGY, INC.
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Dates
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Enumeration Date | 09/08/2008
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Last Update Date | 09/08/2008
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Provider Practice Location Address
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Address Line | 2124 DUPONT AVE S 104
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City | MINNEAPOLIS
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State | MN
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Zip | 55405-2700
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Country | US
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Telephone | 612-871-4336
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Fax | 612-929-2331
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Provider Business Mailing Address
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Address Line | 2124 DUPONT AVE S 104
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City | MINNEAPOLIS
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State | MN
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Zip | 55405-2700
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Country | US
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Telephone | 612-871-4336
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Fax | 612-929-2331
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Authorized Official
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Title or Position | PSYCHOLOGIST/OWNER
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Name | DR. SALLY RUTH MOORE
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Credential | PSY. D
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Telephone | 612-871-4336
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP1891
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License Number State | MN
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