Provider Demographics
NPI:1174248025
Name:BALTO, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BALTO
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 1:2502 PACKARD ST UNIT 5410
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-6853
Mailing Address - Country:US
Mailing Address - Phone:651-283-0524
Mailing Address - Fax:
Practice Address - Street 1:621 W LAKE ST STE 350
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2952
Practice Address - Country:US
Practice Address - Phone:612-979-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511080431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical