=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912434309
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN AMANN MSW, LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2017
-----------------------------------------------------
Last Update Date | 05/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 640 JACKSON ST
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-254-4816
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 517 10TH ST N
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54016-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-222-9791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 22645
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------