Provider Demographics
NPI:1831224047
Name:KORMAN, SUSAN KAY (LICSW)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:KAY
Last Name:KORMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 CENTER AVENUE,
Mailing Address - Street 2:SUITE 7 (CCRI)
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-1972
Mailing Address - Country:US
Mailing Address - Phone:218-236-6730
Mailing Address - Fax:218-236-1481
Practice Address - Street 1:725 CENTER AVENUE,
Practice Address - Street 2:SUITE 7 (CCRI)
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-1972
Practice Address - Country:US
Practice Address - Phone:218-236-6730
Practice Address - Fax:218-236-1481
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN81661041C0700X
ND31591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN154218400Medicaid
ND22024Medicare PIN
MN1831224047Medicare PIN