Provider Demographics
NPI:1962562397
Name:STARTUP, SUSAN L (LMSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:STARTUP
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:L
Other - Last Name:WIERENGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:66817 TERRITORIAL RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MI
Mailing Address - Zip Code:49064-8777
Mailing Address - Country:US
Mailing Address - Phone:616-460-2962
Mailing Address - Fax:269-982-0202
Practice Address - Street 1:1901 NILES AVE STE 102
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1615
Practice Address - Country:US
Practice Address - Phone:269-982-7200
Practice Address - Fax:269-982-0202
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010877971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1712452Medicaid
MI20386Medicare UPIN
MI20366Medicare UPIN
MI20378Medicare UPIN
MIOP22320Medicare ID - Type Unspecified
MI750910904Medicare UPIN
MI1712452Medicaid
MI750910902Medicare UPIN
MI750910910Medicare UPIN
MI750910903Medicare UPIN
MI20351Medicare UPIN