Healthcare Provider Details

I. General information

NPI: 1790601144
Provider Name (Legal Business Name): SUSAN ANN VIAENE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4016 TRISTEN AVE
FORT GRATIOT MI
48059-3745
US

IV. Provider business mailing address

4016 TRISTEN AVE
FORT GRATIOT MI
48059-3745
US

V. Phone/Fax

Practice location:
  • Phone: 586-337-3759
  • Fax:
Mailing address:
  • Phone: 586-337-3759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberV500778067041
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: