Provider Demographics
NPI:1447290374
Name:MCMANIMON MOE, ROBERT E (BS, ADC-T)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:MCMANIMON MOE
Suffix:
Gender:M
Credentials:BS, ADC-T
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:EDWARD
Other - Last Name:MOE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:131 HARRIET ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-3177
Mailing Address - Country:US
Mailing Address - Phone:507-454-2839
Mailing Address - Fax:507-454-5864
Practice Address - Street 1:131 HARRIET ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3177
Practice Address - Country:US
Practice Address - Phone:507-454-2839
Practice Address - Fax:507-454-5864
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNADC-T101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39344000Medicaid