Provider Demographics
NPI:1891484556
Name:SUSTARICH, AVA CORIN
Entity type:Individual
Prefix:
First Name:AVA
Middle Name:CORIN
Last Name:SUSTARICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38550 GARFIELD RD STE B
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3406
Mailing Address - Country:US
Mailing Address - Phone:586-741-6208
Mailing Address - Fax:586-741-6210
Practice Address - Street 1:33464 SCHOENHERR RD. SUITE 180
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312
Practice Address - Country:US
Practice Address - Phone:586-999-5971
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2025-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-24-402238106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician