Provider Demographics
NPI:1104974674
Name:HOISINGTON, SUSAN MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:HOISINGTON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15245 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CENTER CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55012-9640
Mailing Address - Country:US
Mailing Address - Phone:651-213-4197
Mailing Address - Fax:651-213-4411
Practice Address - Street 1:2120 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3378
Practice Address - Country:US
Practice Address - Phone:612-872-2000
Practice Address - Fax:612-871-1375
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0881103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1104974674Medicaid