Provider Demographics
NPI:1194826586
Name:NEUTTILA, SUSAN ANNETTE (ALCOHOL DRUG COUNSEL)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANNETTE
Last Name:NEUTTILA
Suffix:
Gender:F
Credentials:ALCOHOL DRUG COUNSEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 S 13TH ST
Mailing Address - Street 2:DETOX RANGE TREATMENT CENTER
Mailing Address - City:VIRGINA
Mailing Address - State:MN
Mailing Address - Zip Code:55792
Mailing Address - Country:US
Mailing Address - Phone:218-741-9120
Mailing Address - Fax:218-741-3170
Practice Address - Street 1:626 S 13TH ST
Practice Address - Street 2:DETOX RANGE TREATMENT CENTER
Practice Address - City:VIRGINA
Practice Address - State:MN
Practice Address - Zip Code:55792
Practice Address - Country:US
Practice Address - Phone:218-741-9120
Practice Address - Fax:218-741-3170
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN300410101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)