Provider Demographics
NPI:1790558781
Name:TENNYSON, SUSAN M (EDS)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:TENNYSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:M
Other - Last Name:COSTELLO-TENNYSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:EDS
Mailing Address - Street 1:6997 ARCHER CT
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55077-1001
Mailing Address - Country:US
Mailing Address - Phone:612-345-1224
Mailing Address - Fax:
Practice Address - Street 1:6997 ARCHER CT
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55077-1001
Practice Address - Country:US
Practice Address - Phone:612-345-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN375648101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool