Provider Demographics
NPI:1356475552
Name:TODD, GLEN (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:
Last Name:TODD
Suffix:
Gender:M
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 42ND AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-4043
Mailing Address - Country:US
Mailing Address - Phone:612-743-2981
Mailing Address - Fax:
Practice Address - Street 1:4405 42ND AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-4043
Practice Address - Country:US
Practice Address - Phone:612-743-2981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical