Provider Demographics
NPI:1407088958
Name:MOSTOLLER, DANA M
Entity Type:Individual
Prefix:MS
First Name:DANA
Middle Name:M
Last Name:MOSTOLLER
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:DANA
Other - Middle Name:M
Other - Last Name:MOSTOLLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:659 BIELENBERG DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1707
Mailing Address - Country:US
Mailing Address - Phone:612-274-7419
Mailing Address - Fax:651-259-9780
Practice Address - Street 1:659 BIELENBERG DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1707
Practice Address - Country:US
Practice Address - Phone:612-274-7419
Practice Address - Fax:651-259-9780
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN208491041C0700X
SC93541041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1508814625Medicaid
SC1508814625Medicaid