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General NPI Number Information
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NPI Number | 1598644007
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Entity Type | Individual
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Provider Name | SYDNEY RAE MOUG LICSW
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Gender | Female
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Dates
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Enumeration Date | 08/28/2025
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Last Update Date | 08/28/2025
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Provider Practice Location Address
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Address Line | 4510 77TH ST W
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City | EDINA
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State | MN
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Zip | 55435-5505
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Country | US
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Telephone | 952-567-6600
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Fax |
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Provider Business Mailing Address
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Address Line | 10826 FRANCE AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55431-3628
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Country | US
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Telephone | 701-215-2768
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 28880
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License Number State | MN
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