Provider Demographics
NPI:1598440406
Name:SKUSA, MARNE MARIE
Entity Type:Individual
Prefix:
First Name:MARNE
Middle Name:MARIE
Last Name:SKUSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARNE
Other - Middle Name:
Other - Last Name:THONGPUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1829 HAYES ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4731
Mailing Address - Country:US
Mailing Address - Phone:612-708-5998
Mailing Address - Fax:
Practice Address - Street 1:406 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-1901
Practice Address - Country:US
Practice Address - Phone:612-708-5998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLIC360873225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist