Provider Demographics
NPI:1558832352
Name:OSTERTAG, TODD (LADC)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:OSTERTAG
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7766 HIGHWAY 65 NE
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55432-2868
Mailing Address - Country:US
Mailing Address - Phone:763-789-4895
Mailing Address - Fax:763-789-4798
Practice Address - Street 1:7766 HIGHWAY 65 NE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:55432-2868
Practice Address - Country:US
Practice Address - Phone:763-789-4895
Practice Address - Fax:763-789-4798
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303780101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)