Provider Demographics
NPI:1881607844
Name:BROWN, SUSAN CECELIA (MA LP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CECELIA
Last Name:BROWN
Suffix:
Gender:F
Credentials:MA LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 WISE RD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-6004
Mailing Address - Country:US
Mailing Address - Phone:218-251-1554
Mailing Address - Fax:
Practice Address - Street 1:102 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3586
Practice Address - Country:US
Practice Address - Phone:218-251-1554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1154103TA0700X, 103TC0700X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN338R9BROtherBLUE SHEILD MN
MN338R8BROtherBLUE SHEILD MN