Organization
PARKSIDE PSYCHOLOGY, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SALLY RUTH MOORE PSY. D (PSYCHOLOGIST/OWNER)
(612) 871-4336
Entity
Organization
Contact information
Practice address
2124 DUPONT AVE S, 104, MINNEAPOLIS, MN 55405-2700
(612) 871-4336
(612) 929-2331
Mailing address
2124 DUPONT AVE S, 104, MINNEAPOLIS, MN 55405-2700
(612) 871-4336
(612) 929-2331
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
LP1891
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
621853900
—
MN
01
—
67Q05MO
BCBSMN
MN
Enumeration date
09/08/2008
Last updated
09/08/2008
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