Provider Demographics
NPI:1659526622
Name:DUSTIN, SUSAN ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:ANN
Last Name:DUSTIN
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 1:7171 MID OAKS AVE N
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-5233
Mailing Address - Country:US
Mailing Address - Phone:651-430-3933
Mailing Address - Fax:
Practice Address - Street 1:4655 NICOLS RD
Practice Address - Street 2:SUITE 206
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-3425
Practice Address - Country:US
Practice Address - Phone:952-936-2800
Practice Address - Fax:651-405-0358
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN77221041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical