Provider Demographics
NPI:1174730840
Name:SUKOCHEV, VITALY ANA (MA)
Entity type:Individual
Prefix:
First Name:VITALY
Middle Name:ANA
Last Name:SUKOCHEV
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:VITALIY
Other - Middle Name:ANATOLYEVICH
Other - Last Name:SUKOCHEV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SOCIAL SCIENCE
Mailing Address - Street 1:1385 MENDOTA HEIGHTS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120
Mailing Address - Country:US
Mailing Address - Phone:651-379-9800
Mailing Address - Fax:651-405-0358
Practice Address - Street 1:1385 MENDOTA HEIGHTS RD STE 200
Practice Address - Street 2:
Practice Address - City:MENDOTA HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55120
Practice Address - Country:US
Practice Address - Phone:651-379-9800
Practice Address - Fax:651-405-0358
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2047106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist