Individual
SUSAN GUSTAFSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LP
Contact information
Practice address
219 SE MAIN ST STE 400, MINNEAPOLIS, MN 55414-2151
(612) 886-2524
(612) 886-2538
Mailing address
219 SE MAIN ST STE 400, MINNEAPOLIS, MN 55414-2151
(612) 886-2524
(612) 886-2538
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
LP3594
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
025523800
—
FM
01
—
54P16GU
BCBS
MN
01
—
6153482
MEDICA CHOICE
MN
01
—
HP49453
HEALTHPARTNERS
MN
Enumeration date
11/15/2006
Last updated
08/04/2017
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