Healthcare Provider Details

I. General information

NPI: 1336257633
Provider Name (Legal Business Name): SUSAN TAYLOR MSW CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15209 W MICHIGAN AVE
MARSHALL MI
49068-9570
US

IV. Provider business mailing address

15209 W MICHIGAN AVE
MARSHALL MI
49068-9570
US

V. Phone/Fax

Practice location:
  • Phone: 269-781-9119
  • Fax: 269-781-7872
Mailing address:
  • Phone: 269-781-9119
  • Fax: 269-781-7872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801021518
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101005984
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: