Provider Demographics
NPI:1841527488
Name:PRESTRIDGE, SUZANNE MARY (MA)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:MARY
Last Name:PRESTRIDGE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-3585
Mailing Address - Country:US
Mailing Address - Phone:507-200-2624
Mailing Address - Fax:
Practice Address - Street 1:201 N BROAD ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-3585
Practice Address - Country:US
Practice Address - Phone:507-200-2624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-03
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPCC00659101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1841527488Medicaid