Provider Demographics
NPI:1548709140
Name:DERHEIM, SUZANNE E (LMFT)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:E
Last Name:DERHEIM
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 94TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55443-1992
Mailing Address - Country:US
Mailing Address - Phone:763-762-8835
Mailing Address - Fax:763-315-6678
Practice Address - Street 1:5500 94TH AVE N
Practice Address - Street 2:
Practice Address - City:BROOKLYN PARK
Practice Address - State:MN
Practice Address - Zip Code:55443-1992
Practice Address - Country:US
Practice Address - Phone:763-762-8835
Practice Address - Fax:763-315-6678
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2849106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN355355800Medicaid
MNCO1879Medicare UPIN