Basic Information
| Provider Information | |||||||||
| NPI: | 1699728816 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCAMMON | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LICSW, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6516280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1811 WEIR DR STE 270 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551256741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517149646 | ||||||||
| FaxNumber: | 6517149647 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 09/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7573 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 867857000 | 05 | MN | MEDICAID | 5886611 | 01 | AETNA | OTHER | 62-60241 | 01 | MEDICA | OTHER | 01013342 | 01 | PREFERRED ONE | OTHER | 127605 | 01 | MN | U-CARE | OTHER | 855661013342 | 01 | PREFERREDONE ADMINISTRATI | OTHER | 61Q70SI | 01 | BLUE CROSS/BLUE SHIELD | OTHER |