Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TB0200X | Cognitive & Behavioral Psychologist | LP3998 | MN |
NPI | 1174686216 |
---|---|
Provider Name | Ms. Susan A Medo |
First Address | Minneapolis, MN 55404-4341 |
Second Address | Minneapolis, MN 55404-2433 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2006 |
Last Update Date | 17/10/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
210D4ME | BCBS (01) | MN |
756187300 | (05) | MN |