Provider Demographics
NPI:1801193123
Name:ROELLER, SUSAN ROSE (MSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:ROSE
Last Name:ROELLER
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 1:1930 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4708
Mailing Address - Country:US
Mailing Address - Phone:763-427-7964
Mailing Address - Fax:763-427-7976
Practice Address - Street 1:1930 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4708
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN178781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical