Healthcare Provider Details

I. General information

NPI: 1134615826
Provider Name (Legal Business Name): SUSAN LYNN OBRIEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 08/29/2023
Certification Date: 03/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HERITAGE DR STE 520
SOUTHGATE MI
48195-3051
US

IV. Provider business mailing address

1419 E LARNED ST APT 204
DETROIT MI
48207-3073
US

V. Phone/Fax

Practice location:
  • Phone: 734-215-9800
  • Fax:
Mailing address:
  • Phone: 614-323-2332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6401222342
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: