Provider Demographics
NPI:1053466987
Name:SUTTICE, ETHEL M (LMSW ACSW)
Entity Type:Individual
Prefix:MS
First Name:ETHEL
Middle Name:M
Last Name:SUTTICE
Suffix:
Gender:F
Credentials:LMSW ACSW
Other - Prefix:MS
Other - First Name:ETHEL
Other - Middle Name:M
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA CSW
Mailing Address - Street 1:18688 WEST THIRTEEN MILE RD #6
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-258-9587
Mailing Address - Fax:
Practice Address - Street 1:15565 NORTHLAND DRIVE
Practice Address - Street 2:SUITE 505W
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075
Practice Address - Country:US
Practice Address - Phone:248-483-3100
Practice Address - Fax:248-483-3104
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010094991041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OQ264964Medicare ID - Type Unspecified