Provider Demographics
NPI:1417009804
Name:HALL, SUSAN RUTH (PSYCHOLOGIST)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:RUTH
Last Name:HALL
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:RUTH
Other - Last Name:SKURLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1707 MILLER TRUNK HWY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1880
Mailing Address - Country:US
Mailing Address - Phone:218-729-6499
Mailing Address - Fax:218-729-9238
Practice Address - Street 1:1707 MILLER TRUNK HWY
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-1880
Practice Address - Country:US
Practice Address - Phone:218-729-6499
Practice Address - Fax:218-729-9238
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3509103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNPP000OtherFDLHSD UPIN
MN729724600Medicaid