Provider Demographics
NPI:1174064059
Name:SCHRADER, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:SCHRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14551 JUDICIAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-4841
Mailing Address - Country:US
Mailing Address - Phone:952-898-5020
Mailing Address - Fax:952-898-5858
Practice Address - Street 1:14551 JUDICIAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-4841
Practice Address - Country:US
Practice Address - Phone:952-898-5020
Practice Address - Fax:952-898-5858
Is Sole Proprietor?:No
Enumeration Date:2017-03-13
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1476101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND134031915208OtherDRIVER'S LICENSE