Healthcare Provider Details

I. General information

NPI: 1811343866
Provider Name (Legal Business Name): ANDREW MORALES LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2016
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4958 MORGAN AVE N
MINNEAPOLIS MN
55430-3751
US

IV. Provider business mailing address

4958 MORGAN AVE N
MINNEAPOLIS MN
55430-3751
US

V. Phone/Fax

Practice location:
  • Phone: 612-355-9824
  • Fax: 612-355-9824
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number476865
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number22769
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: