MEDICARE: ERIN MICKAELA SUDBECK

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1639821481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN MICKAELA SUDBECK

Provider Business Mailing Address
First Line	:	5868 BAKER RD
Second Line	:
City	:	MINNETONKA
State	:	MN
Zip	:	55345-5903
Country	:	US
Telephone Number	:	952-727-4200
Fax Number	:

Provider Business Practice Location Address
First Line	:	2101 ROLLING GREEN LN
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-4442
Country	:	US
Telephone Number	:	952-767-4200
Fax Number	:

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

Provider Enumeration Date	:	01/24/2022
Last Update Date	:	01/24/2022

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