MEDICARE: SUZANNE SWANSON INC.

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	103TC1900X	Counseling Psychologist	LP2039	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	83A00SW	OTHER	MN	BLUE CROSS BLUE SHIELD MN

General Provider Information

NPI Number	:	1760544290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUZANNE SWANSON INC.

Provider Business Mailing Address
First Line	:	1108 GRAND AVE
Second Line	:	#2
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2618
Country	:	US
Telephone Number	:	651-221-9709
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 GRAND AVE
Second Line	:	#2
City	:	SAINT PAUL
State	:	MN
Zip	:	55105-2618
Country	:	US
Telephone Number	:	651-221-9709
Fax Number	:

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. SUZANNE M SWANSON
Credential	:	PH.D.
Telephone Number	:	651-221-9709

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/22/2020

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