Provider Demographics
NPI:1497773386
Name:HOLTQUIST, SUSANNE ETHEL (MSW, LICSW)
Entity Type:Individual
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First Name:SUSANNE
Middle Name:ETHEL
Last Name:HOLTQUIST
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Gender:F
Credentials:MSW, LICSW
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Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9253
Mailing Address - Fax:651-631-8789
Practice Address - Street 1:13021 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425-7439
Practice Address - Country:US
Practice Address - Phone:218-829-7456
Practice Address - Fax:218-289-7649
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1165891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical