Provider Demographics
NPI:1336239102
Name:SUTHERLAND, TRUDY LYNN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:TRUDY
Middle Name:LYNN
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TRUDY
Other - Middle Name:LYNN
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5219 WAYZATA BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3155
Mailing Address - Country:US
Mailing Address - Phone:952-544-6806
Mailing Address - Fax:952-545-0098
Practice Address - Street 1:5219 WAYZATA BLVD STE 240
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-3155
Practice Address - Country:US
Practice Address - Phone:952-544-6806
Practice Address - Fax:952-545-0098
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN177641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN113352OtherUCARE
MN95G88SUOtherBCBS
MN990991046894OtherPREFERRED ONE
MNHP60858OtherHEALTH PARTNERS
MN62-77673OtherMEDICA