Provider Demographics
NPI:1144399759
Name:PERSONS, SUSAN E (MS, LP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:PERSONS
Suffix:
Gender:F
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 RIVER DR S
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1768
Mailing Address - Country:US
Mailing Address - Phone:651-565-0126
Mailing Address - Fax:651-565-0126
Practice Address - Street 1:1000 LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9449
Practice Address - Country:US
Practice Address - Phone:218-485-5419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2011-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3599103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6280251000Medicaid