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NPI Code Detail

MEDICARE: SUSAN MARIE BANAL LICSW

MEDICARE: SUSAN MARIE BANAL LICSW
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
11041C0700XClinical Social Worker9380MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1629190814
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN MARIE BANAL LICSW
Provider Business Mailing Address
First Line : 4502 TIMBER WOODS LN
Second Line :
City : MINNETONKA
State : MN
Zip : 55345-2973
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5821 CEDAR LAKE RD S
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55416-1487
Country : US
Telephone Number : 651-647-1900
Fax Number : 651-647-1861
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/06/2007
Last Update Date : 04/19/2017

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Directions to “ SUSAN MARIE BANAL LICSW” Practice Location

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