Provider Demographics
NPI:1245561711
Name:WASILK, SUSAN C (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:WASILK
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13750 CROSSTOWN DR NW
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ANDOVER
Mailing Address - State:MN
Mailing Address - Zip Code:55304-5853
Mailing Address - Country:US
Mailing Address - Phone:612-388-1543
Mailing Address - Fax:
Practice Address - Street 1:13750 CROSSTOWN DR NW
Practice Address - Street 2:SUITE 106
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-5853
Practice Address - Country:US
Practice Address - Phone:612-388-1543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-23
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN141771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical