Basic Information
| Provider Information | |||||||||
| NPI: | 1790493088 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SWAGGERT | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | |||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1811 WEIR DR STE 270 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551256741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517149646 | ||||||||
| FaxNumber: | 6517149647 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 WEIR DR STE 270 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551256741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517149646 | ||||||||
| FaxNumber: | 6517149647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2022 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 304688 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 101YA0400X | 05 | MN | MEDICAID |