Healthcare Provider Details

I. General information

NPI: 1073296752
Provider Name (Legal Business Name): SUSAN L MANTURUK LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 E WASHINGTON AVE STE 330-D
JACKSON MI
49201-2393
US

IV. Provider business mailing address

209 E WASHINGTON AVE STE 330-D
JACKSON MI
49201-2393
US

V. Phone/Fax

Practice location:
  • Phone: 517-539-1216
  • Fax:
Mailing address:
  • Phone: 517-539-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401006619
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: