Provider Demographics
NPI:1093928996
Name:IMHOFF, SUSAN MARGARET (MA-CCC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARGARET
Last Name:IMHOFF
Suffix:
Gender:F
Credentials:MA-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 MONTANA AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-2246
Mailing Address - Country:US
Mailing Address - Phone:651-955-7004
Mailing Address - Fax:
Practice Address - Street 1:1111 MONTANA AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-2246
Practice Address - Country:US
Practice Address - Phone:651-955-7004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist