Healthcare Provider Details

I. General information

NPI: 1659526622
Provider Name (Legal Business Name): SUSAN ANN DUSTIN LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 NICOLS RD SUITE 206
EAGAN MN
55122-3425
US

IV. Provider business mailing address

7171 MID OAKS AVE N
STILLWATER MN
55082-5233
US

V. Phone/Fax

Practice location:
  • Phone: 952-936-2800
  • Fax: 651-405-0358
Mailing address:
  • Phone: 651-430-3933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7722
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: