Provider Demographics
NPI:1346383114
Name:MALOUF, SUSAN MARIE (LP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:MALOUF
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:OGELEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1930 COON RAPIDS BLVD
Mailing Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-427-7964
Mailing Address - Fax:763-427-7976
Practice Address - Street 1:1930 COON RAPIDS BLVD
Practice Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4772103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1050077OtherPREFERRED ONE
MN211697000Medicaid
MNHP77003OtherHEALTH PARTNERS
MN019N1MAOtherBCBS
MN109377OtherU CARE
MN019N1MAOtherBCBS