MEDICARE: SUSAN MARGARET IMHOFF MA-CCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	5154	MN

General Provider Information

NPI Number	:	1093928996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN MARGARET IMHOFF MA-CCC

Provider Business Mailing Address
First Line	:	1111 MONTANA AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55108-2246
Country	:	US
Telephone Number	:	651-955-7004
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 MONTANA AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55108-2246
Country	:	US
Telephone Number	:	651-955-7004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/07/2007
Last Update Date	:	03/24/2014

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