Provider Demographics
NPI:1831261742
Name:PACYGA, SUSAN RAE (LICSW LMFT)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:RAE
Last Name:PACYGA
Suffix:
Gender:F
Credentials:LICSW LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2358 SUMAC WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:613-330-7098
Mailing Address - Fax:
Practice Address - Street 1:17305 CEDAR AVE SOUTH
Practice Address - Street 2:SUITE 230
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044
Practice Address - Country:US
Practice Address - Phone:952-435-4144
Practice Address - Fax:952-435-4149
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN066731041C0700X
WI6837-1231041C0700X
MN0648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN552GPAOtherBCBS