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General NPI Number Information
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NPI Number | 1972232122
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Entity Type | Organization
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Legal Business Name | SISU MICHIGAN LLC
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Dates
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Enumeration Date | 06/05/2022
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Last Update Date | 06/05/2022
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Provider Practice Location Address
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Address Line | 2222 W GRAND RIVER AVE STE A
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City | OKEMOS
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State | MI
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Zip | 48864-1604
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Country | US
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Telephone | 989-403-0192
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Fax |
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Provider Business Mailing Address
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Address Line | 1363 N GARFIELD RD
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City | LINWOOD
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State | MI
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Zip | 48634-9759
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Country | US
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Telephone | 989-751-7854
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Fax |
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Authorized Official
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Title or Position | SOCIAL WORKER/ CEO
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Name | DANYELLE E WAGNER
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Credential | LMSW, CAADC
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Telephone | 989-403-0192
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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