Provider Demographics
NPI:1376938613
Name:TODD GJERDEVIG
Entity Type:Organization
Organization Name:TODD GJERDEVIG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:GJERDEVIG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:817-908-0296
Mailing Address - Street 1:1111 S MAIN ST
Mailing Address - Street 2:SUITE 132
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5577
Mailing Address - Country:US
Mailing Address - Phone:817-865-5032
Mailing Address - Fax:
Practice Address - Street 1:1111 S MAIN ST
Practice Address - Street 2:SUITE 132
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5577
Practice Address - Country:US
Practice Address - Phone:817-865-5032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX375071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207198701Medicaid
TX8L12516Medicare PIN