Provider Demographics
NPI:1952336265
Name:SANDSMARK, SUZANNE R (RPT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:R
Last Name:SANDSMARK
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:R
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3838 12TH AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2931
Practice Address - Country:US
Practice Address - Phone:701-234-4700
Practice Address - Fax:701-234-4757
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2824225100000X
ND538225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN313645100Medicaid
ND52081Medicaid