Healthcare Provider Details

I. General information

NPI: 1033353669
Provider Name (Legal Business Name): TODD BORSTAD LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 O'LEARY LANE
EAGAN MN
55123
US

IV. Provider business mailing address

3450 OLEARY LN
EAGAN MN
55123-2340
US

V. Phone/Fax

Practice location:
  • Phone: 651-454-0114
  • Fax: 651-454-3492
Mailing address:
  • Phone: 651-454-0114
  • Fax: 651-454-9492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17389
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: