Healthcare Provider Details

I. General information

NPI: 1962423301
Provider Name (Legal Business Name): SUSAN LYNN PARKER MALLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 PLYMOUTH RD SUITE #125
PLYMOUTH MI
48170-1497
US

IV. Provider business mailing address

409 PLYMOUTH RD #125
PLYMOUTH MI
48170-4080
US

V. Phone/Fax

Practice location:
  • Phone: 734-404-7002
  • Fax: 734-233-9733
Mailing address:
  • Phone: 734-404-7002
  • Fax: 734-233-9733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301009018
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: