Provider Demographics
NPI:1154434959
Name:MAHALIK, SUSAN (MSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:MAHALIK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13465 STRATHCONA AVENUE
Mailing Address - Street 2:APT. 209
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195
Mailing Address - Country:US
Mailing Address - Phone:734-282-2215
Mailing Address - Fax:
Practice Address - Street 1:2514 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-7891
Practice Address - Country:US
Practice Address - Phone:517-775-4248
Practice Address - Fax:734-282-2215
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010788861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0899332OtherBCBSM PROVIDER PIN
MI0899332OtherBCBSM PROVIDER PIN