Provider Demographics
NPI:1609952027
Name:BACK, SUSAN MARIE (MS LP)
Entity Type:Individual
Prefix:MISS
First Name:SUSAN
Middle Name:MARIE
Last Name:BACK
Suffix:
Gender:F
Credentials:MS LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:116 COUNTY ROAD 34 W
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143
Mailing Address - Country:US
Mailing Address - Phone:507-847-5952
Mailing Address - Fax:507-847-5275
Practice Address - Street 1:116 COUNTY ROAD 34 W
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143
Practice Address - Country:US
Practice Address - Phone:507-847-5952
Practice Address - Fax:507-847-5275
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1191103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist