Provider Demographics
NPI:1528040342
Name:KISH, SUZANNE L (PSYD, LP)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:L
Last Name:KISH
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:L
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD, LP
Mailing Address - Street 1:1500 MCANDREWS RD W STE 223
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-4445
Mailing Address - Country:US
Mailing Address - Phone:952-854-7771
Mailing Address - Fax:
Practice Address - Street 1:1500 MCANDREWS RD W STE 223
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-4445
Practice Address - Country:US
Practice Address - Phone:952-854-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3833103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN670522700Medicaid