Healthcare Provider Details

I. General information

NPI: 1730317132
Provider Name (Legal Business Name): TODD JEFFREY MONGER LPCC, NCC, ACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 GAME FARM RD N
MAPLE PLAIN MN
55359
US

IV. Provider business mailing address

1272 HOMESTEAD TRL
LONG LAKE MN
55356-9687
US

V. Phone/Fax

Practice location:
  • Phone: 952-221-5625
  • Fax:
Mailing address:
  • Phone: 952-221-5625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number00034
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: