Provider Demographics
NPI:1063065019
Name:DOLPH, SUSAN M (LICSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:DOLPH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5723 GRAND AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-2567
Mailing Address - Country:US
Mailing Address - Phone:218-461-6468
Mailing Address - Fax:218-212-9933
Practice Address - Street 1:5723 GRAND AVE STE 2
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55807-2567
Practice Address - Country:US
Practice Address - Phone:218-461-6468
Practice Address - Fax:218-212-9933
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9614-1231041C0700X
MN133591041S0200X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool