Provider Demographics
NPI:1073764957
Name:GJERDEVIG, TODD ALLEN (LCSW)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:ALLEN
Last Name:GJERDEVIG
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 STATE ST STE 225
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7632
Mailing Address - Country:US
Mailing Address - Phone:817-908-0296
Mailing Address - Fax:
Practice Address - Street 1:180 STATE ST STE 225
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7632
Practice Address - Country:US
Practice Address - Phone:817-908-0296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-09
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX375071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207198701Medicaid
TX207198701Medicaid