Provider Demographics
NPI:1063663714
Name:SUPAN, MARITACONSTANCE (PHD, LLP, DAPA)
Entity Type:Individual
Prefix:DR
First Name:MARITACONSTANCE
Middle Name:
Last Name:SUPAN
Suffix:
Gender:F
Credentials:PHD, LLP, DAPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 MASON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2215
Mailing Address - Country:US
Mailing Address - Phone:313-278-8053
Mailing Address - Fax:313-278-8053
Practice Address - Street 1:934 MASON ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2215
Practice Address - Country:US
Practice Address - Phone:313-278-8053
Practice Address - Fax:313-278-8053
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008934103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI48210ONMedicare PIN