MEDICARE: SUSAN ELIZABETH SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	1589	MN

General Provider Information

NPI Number	:	1528235264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN ELIZABETH SMITH

Provider Business Mailing Address
First Line	:	7040 LAKELAND AVE N
Second Line	:	208
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-5600
Country	:	US
Telephone Number	:	763-560-8331
Fax Number	:

Provider Business Practice Location Address
First Line	:	7040 LAKELAND AVE N
Second Line	:	208
City	:	BROOKLYN PARK
State	:	MN
Zip	:	55428-5600
Country	:	US
Telephone Number	:	763-560-8331
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2008
Last Update Date	:	05/12/2008

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