Provider Demographics
NPI:1861583411
Name:HOLMEN, SUSAN GAIL (LICSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:GAIL
Last Name:HOLMEN
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 1:325 N 33RD AVE
Mailing Address - Street 2:103
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-253-3715
Mailing Address - Fax:320-252-2567
Practice Address - Street 1:325 N 33RD AVE
Practice Address - Street 2:103
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-3715
Practice Address - Fax:320-252-2567
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN17807104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker