Provider Demographics
NPI:1770622086
Name:DICKEY, SUSAN E (DC)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:E
Last Name:DICKEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4143 MINNEHAHA AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3339
Mailing Address - Country:US
Mailing Address - Phone:612-824-4163
Mailing Address - Fax:612-724-4857
Practice Address - Street 1:4143 MINNEHAHA AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-3339
Practice Address - Country:US
Practice Address - Phone:612-824-4163
Practice Address - Fax:612-724-4857
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN003192111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN19092058Medicaid
MN4C766DIOtherBC
MN350002366Medicare ID - Type Unspecified
MN19092058Medicaid