Provider Demographics
NPI:1770641557
Name:KIRK, SUZANNE MARIE (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:MARIE
Last Name:KIRK
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 PARK GLEN RD
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-5427
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-925-8496
Practice Address - Street 1:1015 SIBLEY MEMORIAL HWY APT 106
Practice Address - Street 2:
Practice Address - City:LILYDALE
Practice Address - State:MN
Practice Address - Zip Code:55118-3683
Practice Address - Country:US
Practice Address - Phone:855-727-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN141621041C0700X
MNLICSW14162104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN238688700Medicaid
MN238688700Medicaid