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General NPI Number Information
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NPI Number | 1629190814
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Entity Type | Individual
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Provider Name | SUSAN MARIE BANAL LICSW
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Gender | Female
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Dates
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Enumeration Date | 04/06/2007
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Last Update Date | 04/19/2017
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Provider Practice Location Address
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Address Line | 5821 CEDAR LAKE RD S
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-1487
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Country | US
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Telephone | 651-647-1900
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Fax | 651-647-1861
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Provider Business Mailing Address
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Address Line | 4502 TIMBER WOODS LN
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City | MINNETONKA
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State | MN
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Zip | 55345-2973
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Country | US
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Telephone |
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Fax |
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 9380
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License Number State | MN
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