Provider Demographics
NPI:1720552557
Name:SUTTON, ROBERT HERBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HERBERT
Last Name:SUTTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 EXCELSIOR BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-2734
Mailing Address - Country:US
Mailing Address - Phone:952-548-9340
Mailing Address - Fax:952-548-9350
Practice Address - Street 1:6200 EXCELSIOR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2734
Practice Address - Country:US
Practice Address - Phone:952-548-9340
Practice Address - Fax:952-548-9350
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301693101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNLADCOtherLADC