Healthcare Provider Details

I. General information

NPI: 1376775981
Provider Name (Legal Business Name): SUSSANNE J MARMOL DE MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19445 W WARREN AVE
DETROIT MI
48228-3361
US

IV. Provider business mailing address

1821 E DYER RD STE 200
SANTA ANA CA
92705-5700
US

V. Phone/Fax

Practice location:
  • Phone: 313-207-0088
  • Fax:
Mailing address:
  • Phone: 949-250-0488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: