Provider Demographics
NPI:1831268812
Name:MODAHL, EDWARD C (MS ED LP)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:C
Last Name:MODAHL
Suffix:
Gender:M
Credentials:MS ED LP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:604 WINTER GREEN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-808-9310
Mailing Address - Fax:320-239-1420
Practice Address - Street 1:324 BROADWAY ST STE 206
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1482
Practice Address - Country:US
Practice Address - Phone:320-762-1762
Practice Address - Fax:320-762-0796
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0834103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN218G3MOOtherBLUE CROSS BLUE SHIELD
138070OtherBHP
MN571052900OtherPRIMEWEST HEALTH SYSTEMS
MN571052900Medicaid
6267221OtherUBH