Healthcare Provider Details

I. General information

NPI: 1720552557
Provider Name (Legal Business Name): ROBERT HERBERT SUTTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2019
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 EXCELSIOR BLVD STE 203
ST LOUIS PARK MN
55416-2734
US

IV. Provider business mailing address

6200 EXCELSIOR BLVD STE 204
MINNEAPOLIS MN
55416-2734
US

V. Phone/Fax

Practice location:
  • Phone: 952-548-9340
  • Fax: 952-548-9350
Mailing address:
  • Phone: 952-548-9340
  • Fax: 952-548-9350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number301693
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: