Healthcare Provider Details

I. General information

NPI: 1881730430
Provider Name (Legal Business Name): SUSAN STEWART WHITEAKER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 ROEDER CIR
FORT SNELLING MN
55111-4017
US

IV. Provider business mailing address

8663 OAK HILL CIR
PRIOR LAKE MN
55372-9187
US

V. Phone/Fax

Practice location:
  • Phone: 612-713-3255
  • Fax: 612-713-3992
Mailing address:
  • Phone: 612-991-8997
  • Fax: 612-713-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11771
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: