Provider Demographics
NPI:1629190814
Name:BANAL, SUSAN MARIE (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:BANAL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 TIMBER WOODS LN
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5821 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1487
Practice Address - Country:US
Practice Address - Phone:651-647-1900
Practice Address - Fax:651-647-1861
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN93801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1629190814Medicaid
MNH400314785Medicare PIN