Edward C Modahl, MS ED LP

Primary specialty

PsychologistTaxonomy code 103T00000X

License

LP0834 Issued in MN

Practice address

324 Broadway St Ste 206
Alexandria, MN 56308-1482

Phone

(320) 762-1762

Fax

(320) 762-0796

NPI assigned

Nov 6, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 5

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Minnewaska Area Schools #2149

  • Adolescent and Children Mental Health Clinic/Center
  • Starbuck, MN
  • NPI 1306913017
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162771200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1714953600000",
    "number": "1831268812",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "604 WINTER GREEN",
            "city": "ALEXANDRIA",
            "state": "MN",
            "postal_code": "56308",
            "telephone_number": "320-808-9310",
            "fax_number": "320-239-1420"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "324 BROADWAY ST STE 206",
            "city": "ALEXANDRIA",
            "state": "MN",
            "postal_code": "563081482",
            "telephone_number": "320-762-1762",
            "fax_number": "320-762-0796"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MODAHL",
        "first_name": "EDWARD",
        "middle_name": "C",
        "name_prefix": "Mr.",
        "credential": "MS ED LP",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-06",
        "last_updated": "2024-05-06",
        "certification_date": "2024-05-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103T00000X",
            "taxonomy_group": "",
            "desc": "Psychologist",
            "state": "MN",
            "license": "LP0834",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "218G3MO",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BHP",
            "identifier": "138070",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PRIMEWEST HEALTH SYSTEMS",
            "identifier": "571052900",
            "state": "MN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "571052900",
            "state": "MN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "UBH",
            "identifier": "6267221",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Jacquelyn J Miron, R.PH
• Shanna Mitchell
• Dane Jason Mitteness, M.D.
• Lisa Kay Mitteness, OTR/L, BCBA
• Collin Ross Modahl, LP
• Maralee Karen Moen, COTA/L
• Melissa Moenkedick, DPT
• Betsy Ann Moga, CFNP
• Elizabeth Ann Mohror-Hill, OTR/L, CHT
• Moments Hospice of Alexandria LLC

• Psychologist in Alexandria, MN
• Providers in Alexandria, MN by specialty
• Psychologist in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.