Provider Demographics
NPI:1366514242
Name:MOEN, RICHELLE N (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHELLE
Middle Name:N
Last Name:MOEN
Suffix:
Gender:F
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:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - Street 2:2312 SOUTH 6TH STREET, SUITE F256, 2B W
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55454
Mailing Address - Country:US
Mailing Address - Phone:612-273-8700
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - Street 2:2312 SOUTH 6TH STREET, SUITE F256, 2B W
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-273-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP2440103T00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1012203OtherPREFERRED ONE
8D932MOOtherBLUE CROSS BLUE SHIELD
MN922250200Medicaid
ND17886Medicaid
HP28967OtherHEALTH PARTNERS
106588OtherUCARE
61-30122OtherMEDICA CHOICE
61-30122OtherMEDICA PRIMARY
768274OtherARAZ
68000937Medicare ID - Type Unspecified
61-30122OtherMEDICA PRIMARY
768274OtherARAZ