Provider Demographics
NPI:1033219548
Name:GRONQUIST, SUSAN M (MSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:M
Last Name:GRONQUIST
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 STARBROOK DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-6041
Mailing Address - Country:US
Mailing Address - Phone:704-552-2704
Mailing Address - Fax:704-331-0859
Practice Address - Street 1:249 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1003
Practice Address - Country:US
Practice Address - Phone:704-336-4053
Practice Address - Fax:704-331-0859
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC15086OtherPROVIDER NUMBER