Provider Demographics
NPI:1962423301
Name:PARKER, SUSAN LYNN (MALLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:PARKER
Suffix:
Gender:F
Credentials:MALLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 PLYMOUTH RD
Mailing Address - Street 2:#125
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4080
Mailing Address - Country:US
Mailing Address - Phone:734-404-7002
Mailing Address - Fax:734-233-9733
Practice Address - Street 1:409 PLYMOUTH RD
Practice Address - Street 2:SUITE #125
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1497
Practice Address - Country:US
Practice Address - Phone:734-404-7002
Practice Address - Fax:734-233-9733
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009018103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling