Provider Demographics
NPI:1063591147
Name:HENDRICKSON, SUSAN M (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:M
Last Name:HENDRICKSON
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 PARKLAWN AVE STE 415
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5129
Mailing Address - Country:US
Mailing Address - Phone:612-845-8768
Mailing Address - Fax:
Practice Address - Street 1:7600 PARKLAWN AVE STE 415
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5129
Practice Address - Country:US
Practice Address - Phone:612-845-8768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4455103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN937451500OtherMN HEALTH CARE PROGRAMS
MN404K4HEOtherBLUE CROSS BLUE SHIELD MN