Provider Demographics
NPI:1992747042
Name:HERZOG, SUSAN KAY (LICSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAY
Last Name:HERZOG
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:KAY
Other - Last Name:MCWILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:200 E MAIN AVE
Mailing Address - Street 2:SUITE 102-A
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3857
Mailing Address - Country:US
Mailing Address - Phone:701-471-1044
Mailing Address - Fax:
Practice Address - Street 1:1110 COLLEGE DR
Practice Address - Street 2:SUITE 215
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1207
Practice Address - Country:US
Practice Address - Phone:701-471-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2010-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5131041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
N16133OtherRR MEDICARE PIN
ND19187Medicaid
016133OtherBCBS OF ND PIN
016133OtherBCBS OF ND PIN
ND712837Medicare PIN