Provider Demographics
NPI:1497836480
Name:CHUNG, SUZZANNE (PSYD LP)
Entity Type:Individual
Prefix:DR
First Name:SUZZANNE
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10591 165TH ST W
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-3528
Mailing Address - Country:US
Mailing Address - Phone:952-898-1133
Mailing Address - Fax:952-435-6797
Practice Address - Street 1:10591 165TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-3528
Practice Address - Country:US
Practice Address - Phone:952-898-1133
Practice Address - Fax:952-435-6797
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP 4658103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN955796200Medicaid