1114175791 NPI number — PARKSIDE PSYCHOLOGY, INC.

Table of content: (NPI 1114175791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114175791 NPI number — PARKSIDE PSYCHOLOGY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKSIDE PSYCHOLOGY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114175791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2124 DUPONT AVE S
Provider Second Line Business Practice Location Address:
104
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55405-2700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-871-4336
Provider Business Practice Location Address Fax Number:
612-929-2331
Provider Enumeration Date:
09/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
SALLY
Authorized Official Middle Name:
RUTH
Authorized Official Title or Position:
PSYCHOLOGIST/OWNER
Authorized Official Telephone Number:
612-871-4336

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP1891 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 621853900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 67Q05MO . This is a "BCBSMN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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