Healthcare Provider Details

I. General information

NPI: 1255760591
Provider Name (Legal Business Name): SUSAN GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2013
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 DAHLIA DR RM E315
LANSING MI
48911-3789
US

IV. Provider business mailing address

PO BOX 30161
LANSING MI
48909-7661
US

V. Phone/Fax

Practice location:
  • Phone: 517-272-4115
  • Fax:
Mailing address:
  • Phone: 517-887-4383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115039
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: