Provider Demographics
NPI:1538754569
Name:MOE, CINDY RAE (LP)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:RAE
Last Name:MOE
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 LOWRY AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1370
Mailing Address - Country:US
Mailing Address - Phone:612-910-1035
Mailing Address - Fax:
Practice Address - Street 1:8590 EDINBURGH CENTER DR
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-3723
Practice Address - Country:US
Practice Address - Phone:763-425-5959
Practice Address - Fax:763-425-5929
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPOO94103T00000X
MNLP0094103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA818440000Medicaid