Provider Demographics
NPI:1053841825
Name:MALOTT, SUSAN REBECCA
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:REBECCA
Last Name:MALOTT
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 1:1410 S TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1410 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-0046
Practice Address - Country:US
Practice Address - Phone:248-456-8153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704180080163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult