Provider Demographics
NPI:1104960061
Name:MOONEY, MARC (PHD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:MOONEY
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7766 HIGHWAY 65 NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2832
Mailing Address - Country:US
Mailing Address - Phone:763-205-4843
Mailing Address - Fax:612-416-2085
Practice Address - Street 1:7766 HIGHWAY 65 NE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-2832
Practice Address - Country:US
Practice Address - Phone:763-205-4843
Practice Address - Fax:612-416-2085
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4773103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist