1699728816 NPI number — SUSAN J MCCAMMON LICSW, MA

Table of content: SUSAN J MCCAMMON LICSW, MA (NPI 1699728816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699728816 NPI number — SUSAN J MCCAMMON LICSW, MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCAMMON
Provider First Name:
SUSAN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICSW, MA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699728816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 SILVER LAKE RD NW STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BRIGHTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55112-1789
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-628-9566
Provider Business Mailing Address Fax Number:
651-628-0411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 WEIR DR STE 270
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-6741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-714-9646
Provider Business Practice Location Address Fax Number:
651-714-9647
Provider Enumeration Date:
05/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  7573 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 867857000 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5886611 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 62-60241 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01013342 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 127605 . This is a "U-CARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 855661013342 . This is a "PREFERREDONE ADMINISTRATI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 61Q70SI . This is a "BLUE CROSS/BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com