Provider Demographics
NPI:1053434159
Name:WENSTROM POCRNICH, SUZANNE GAYLE (MS, LP)
Entity type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:GAYLE
Last Name:WENSTROM POCRNICH
Suffix:
Gender:M
Credentials:MS, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:798 307TH TRL NE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MN
Mailing Address - Zip Code:55008-6016
Mailing Address - Country:US
Mailing Address - Phone:763-444-7068
Mailing Address - Fax:
Practice Address - Street 1:133 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1552
Practice Address - Country:US
Practice Address - Phone:763-689-9407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3820103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling