Provider Demographics
NPI:1265500755
Name:BOLLINGER-BROWN, SUSAN J (MSSW, LICSW, LCSW-C)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:J
Last Name:BOLLINGER-BROWN
Suffix:
Gender:
Credentials:MSSW, LICSW, LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 SELBY AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-6149
Mailing Address - Country:US
Mailing Address - Phone:651-651-2068
Mailing Address - Fax:651-389-9397
Practice Address - Street 1:1684 SELBY AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-6149
Practice Address - Country:US
Practice Address - Phone:651-206-8955
Practice Address - Fax:651-389-9397
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN130611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1265500755Medicaid