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General NPI Number Information
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NPI Number | 1376938613
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Entity Type | Organization
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Legal Business Name | TODD GJERDEVIG
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Dates
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Enumeration Date | 04/03/2015
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Last Update Date | 04/03/2015
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Provider Practice Location Address
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Address Line | 1111 S MAIN ST SUITE 132
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City | GRAPEVINE
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State | TX
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Zip | 76051-5577
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Country | US
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Telephone | 817-865-5032
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Fax |
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Provider Business Mailing Address
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Address Line | 1111 S MAIN ST SUITE 132
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City | GRAPEVINE
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State | TX
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Zip | 76051-5577
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Country | US
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Telephone | 817-865-5032
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TODD GJERDEVIG
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Credential | LCSW
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Telephone | 817-908-0296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 37507
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License Number State | TX
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