Provider Demographics
NPI:1235337999
Name:GALLUCCI, SUSAN MARIE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARIE
Last Name:GALLUCCI
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5891 CEDAR LAKE RD
Mailing Address - Street 2:#103
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1460
Mailing Address - Country:US
Mailing Address - Phone:952-463-0600
Mailing Address - Fax:
Practice Address - Street 1:5891 CEDAR LAKE RD S # 103
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1460
Practice Address - Country:US
Practice Address - Phone:952-463-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-04
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3124421041S0200X
101YM0800X, 103T00000X, 106H00000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist