Basic Information
| Provider Information | |||||||||
| NPI: | 1104960061 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOONEY | ||||||||
| FirstName: | MARC | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 28TH ST | ||||||||
| Address2: | STE. 600 WASIE | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128635327 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 E 28TH ST | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554073723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128635327 | ||||||||
| FaxNumber: | 6128632896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 06/28/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | LP4773 | MN | N | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | LP4773 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.