Provider Demographics
NPI:1285767590
Name:MORAN, TODD FRANCIS (PHD, LICSW)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:FRANCIS
Last Name:MORAN
Suffix:
Gender:M
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 36TH ST NW
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:MN
Mailing Address - Zip Code:55912-6661
Mailing Address - Country:US
Mailing Address - Phone:507-438-2010
Mailing Address - Fax:507-434-0955
Practice Address - Street 1:308 4TH AVE NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-3140
Practice Address - Country:US
Practice Address - Phone:507-438-2010
Practice Address - Fax:507-434-0955
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
MN15984104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN12345678Medicaid
MN452809300Medicaid