Provider Demographics
NPI:1881730430
Name:WHITEAKER, SUSAN STEWART (LICSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:STEWART
Last Name:WHITEAKER
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8663 OAK HILL CIR
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-9187
Mailing Address - Country:US
Mailing Address - Phone:612-991-8997
Mailing Address - Fax:612-713-3992
Practice Address - Street 1:506 ROEDER CIR
Practice Address - Street 2:
Practice Address - City:FORT SNELLING
Practice Address - State:MN
Practice Address - Zip Code:55111-4017
Practice Address - Country:US
Practice Address - Phone:612-713-3255
Practice Address - Fax:612-713-3992
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical