Healthcare Provider Details

I. General information

NPI: 1447290374
Provider Name (Legal Business Name): ROBERT E MCMANIMON MOE BS, ADC-T
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ROBERT EDWARD MOE

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 10/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 HARRIET ST
WINONA MN
55987-3177
US

IV. Provider business mailing address

131 HARRIET ST
WINONA MN
55987-3177
US

V. Phone/Fax

Practice location:
  • Phone: 507-454-2839
  • Fax: 507-454-5864
Mailing address:
  • Phone: 507-454-2839
  • Fax: 507-454-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADC-T
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: