Healthcare Provider Details

I. General information

NPI: 1083921563
Provider Name (Legal Business Name): SARAH LIETZOW WITHERELL PH.D., LLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH JANICE LIETZOW M.A.

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 E JEFFERSON AVE
DETROIT MI
48207-4180
US

IV. Provider business mailing address

101 E ALEXANDRINE ST
DETROIT MI
48201-2011
US

V. Phone/Fax

Practice location:
  • Phone: 313-993-3434
  • Fax: 313-993-3421
Mailing address:
  • Phone: 313-831-5535
  • Fax: 313-324-8782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6301015705
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: