Provider Demographics
NPI:1205305406
Name:SCHWANKL, SUSAN LEE
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:SCHWANKL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LEE
Other - Last Name:OLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:520 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2902
Mailing Address - Country:US
Mailing Address - Phone:218-829-3235
Mailing Address - Fax:
Practice Address - Street 1:520 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-2902
Practice Address - Country:US
Practice Address - Phone:218-829-3235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-16
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01980101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional