Healthcare Provider Details

I. General information

NPI: 1881602613
Provider Name (Legal Business Name): SUSAN KOTTSCHADE PSY.D., LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 ORLEANS ST E
STILLWATER MN
55082-5830
US

IV. Provider business mailing address

7066 STILLWATER BLVD N
OAKDALE MN
55128-3937
US

V. Phone/Fax

Practice location:
  • Phone: 651-430-2720
  • Fax: 651-251-3155
Mailing address:
  • Phone: 651-777-5222
  • Fax: 651-251-5111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3512
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: