Individual
MR. EDWARD C MODAHL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MS ED LP
Contact information
Practice address
324 BROADWAY ST STE 206, ALEXANDRIA, MN 56308-1482
(320) 762-1762
(320) 762-0796
Mailing address
604 WINTER GREEN, ALEXANDRIA, MN 56308
(320) 808-9310
(320) 239-1420
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
Primary
LP0834
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
138070
BHP
—
01
—
218G3MO
BLUE CROSS BLUE SHIELD
MN
01
—
571052900
PRIMEWEST HEALTH SYSTEMS
MN
05
—
571052900
—
MN
01
—
6267221
UBH
—
Enumeration date
11/06/2006
Last updated
05/06/2024
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