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General NPI Number Information
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NPI Number | 1144399759
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Entity Type | Individual
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Provider Name | SUSAN E. PERSONS MS, LP
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Gender | Female
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Dates
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Enumeration Date | 11/07/2006
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Last Update Date | 07/23/2011
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Provider Practice Location Address
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Address Line | 1000 LAKESHORE DR
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City | MOOSE LAKE
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State | MN
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Zip | 55767-9449
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Country | US
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Telephone | 218-485-5419
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Fax |
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Provider Business Mailing Address
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Address Line | 1609 RIVER DR S
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City | WABASHA
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State | MN
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Zip | 55981-1768
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Country | US
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Telephone | 651-565-0126
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Fax | 651-565-0126
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | LP3599
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 103TP2701X
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Taxonomy Name | Group Psychotherapy Psychologist
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License Number | LP3599
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License Number State | MN
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