Provider Demographics
NPI:1699728816
Name:MCCAMMON, SUSAN J (LICSW, MA)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:MCCAMMON
Suffix:
Gender:F
Credentials:LICSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW STE 110
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1789
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:651-628-0411
Practice Address - Street 1:1811 WEIR DR STE 270
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-6741
Practice Address - Country:US
Practice Address - Phone:651-714-9646
Practice Address - Fax:651-714-9647
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN75731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN867857000Medicaid
5886611OtherAETNA
62-60241OtherMEDICA
01013342OtherPREFERRED ONE
MN127605OtherU-CARE
855661013342OtherPREFERREDONE ADMINISTRATI
61Q70SIOtherBLUE CROSS/BLUE SHIELD