Provider Demographics
NPI:1356555346
Name:BROKAW, SUSAN P
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:P
Last Name:BROKAW
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:PYE
Other - Last Name:BROKAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:5100 THIMSEN AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4108
Mailing Address - Country:US
Mailing Address - Phone:952-933-9926
Mailing Address - Fax:952-474-3558
Practice Address - Street 1:5100 THIMSEN AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4108
Practice Address - Country:US
Practice Address - Phone:952-933-9926
Practice Address - Fax:952-474-3558
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0013106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNON289PYOtherBLUE CROSS BLUE SHIELD