Provider Demographics
NPI:1861047383
Name:BEVEROTH POLLACK, SUZANNE CAROL (LISW)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:CAROL
Last Name:BEVEROTH POLLACK
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:CAROL
Other - Last Name:POLLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-0030
Mailing Address - Country:US
Mailing Address - Phone:651-275-7400
Mailing Address - Fax:651-275-7401
Practice Address - Street 1:14949 62ND ST N
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6132
Practice Address - Country:US
Practice Address - Phone:651-275-7400
Practice Address - Fax:651-275-7401
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7619101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health