Provider Demographics
NPI:1215146881
Name:LARSON, SUZANNE LEE (LICSW)
Entity type:Individual
Prefix:MRS
First Name:SUZANNE
Middle Name:LEE
Last Name:LARSON
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 1:7103 48TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-2648
Mailing Address - Country:US
Mailing Address - Phone:651-777-3112
Mailing Address - Fax:
Practice Address - Street 1:1331 COUNTY ROAD D E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-5260
Practice Address - Country:US
Practice Address - Phone:651-777-3112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN102611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical