Provider Demographics
NPI:1467406652
Name:MATTHIESEN, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MATTHIESEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 20TH ST SW
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-6201
Mailing Address - Country:US
Mailing Address - Phone:701-252-1050
Mailing Address - Fax:701-952-3265
Practice Address - Street 1:2422 20TH ST SW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-6201
Practice Address - Country:US
Practice Address - Phone:701-252-1050
Practice Address - Fax:701-952-3265
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND500231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP42264OtherHEALTH PARTNERS
ND50403Medicaid
ND14484OtherBLUE SHIELD
4500069OtherMEDICA
1006908OtherPREFERRED ONE
HP42264OtherHEALTH PARTNERS
ND640002504Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NDN14884Medicare PIN