MEDICARE: PARKSIDE PSYCHOLOGY, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP1891	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	67Q05MO	OTHER	MN	BCBSMN

General Provider Information

NPI Number	:	1114175791
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARKSIDE PSYCHOLOGY, INC.

Provider Business Mailing Address
First Line	:	2124 DUPONT AVE S
Second Line	:	104
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2700
Country	:	US
Telephone Number	:	612-871-4336
Fax Number	:	612-929-2331

Provider Business Practice Location Address
First Line	:	2124 DUPONT AVE S
Second Line	:	104
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55405-2700
Country	:	US
Telephone Number	:	612-871-4336
Fax Number	:	612-929-2331

Authorized Official
Title or Position	:	PSYCHOLOGIST/OWNER
Name	:	DR. SALLY RUTH MOORE
Credential	:	PSY. D
Telephone Number	:	612-871-4336

Provider Enumeration Date	:	09/08/2008
Last Update Date	:	09/08/2008

Similar Medicare Providers

1467437228 — CARA S BEAMES M.A., L.P.
Practice Location Address:

2124 DUPONT AVE S
MINNEAPOLIS, MN
55405-2700

Practice Phone: 612-874-6640
Practice Fax: 612-879-0059

1356485924 — DR. LARRY L ANDERSON PSYD
Practice Location Address:

2124 DUPONT AVE S STE 202
MINNEAPOLIS, MN
55405-2700

Practice Phone: 612-718-0894
Practice Fax: 612-879-0059

1538382767 — DR. ELLEN UDINE LOGACZ PH.D. LP MA LMFT
Practice Location Address:

2124 DUPONT AVE S , SUITE 301
MINNEAPOLIS, MN
55405-2700

Practice Phone: 612-824-9528
Practice Fax:

1598976698 — KENFIELD AND ASSOCIATES, P.C.
Practice Location Address:

2124 DUPONT AVE S , SUITE 300
MINNEAPOLIS, MN
55405-2700

Practice Phone: 612-879-1010
Practice Fax:

1306038328 — DR. JULIE A KENFIELD PH.D.
Practice Location Address:

2124 DUPONT AVE S , SUITE 300
MINNEAPOLIS, MN
55405-2700

Practice Phone: 612-879-1010
Practice Fax:

1881850980 — JENNIFER CONNELL LAC
Practice Location Address:

2124 DUPONT AVE S
MINNEAPOLIS, MN
55405-2700

Practice Phone: 612-824-8080
Practice Fax:

Directions to “PARKSIDE PSYCHOLOGY, INC. ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.