Provider Demographics
NPI:1174686216
Name:MEDO, SUSAN A (MA LP)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:A
Last Name:MEDO
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2530 1ST AVE S
Mailing Address - Street 2:#301
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4341
Mailing Address - Country:US
Mailing Address - Phone:612-203-8088
Mailing Address - Fax:
Practice Address - Street 1:100 W FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-2433
Practice Address - Country:US
Practice Address - Phone:612-203-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3998103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN210D4MEOtherBCBS
MN756187300Medicaid