Provider Demographics
NPI:1073296752
Name:MANTURUK, SUSAN L (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:MANTURUK
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E WASHINGTON AVE STE 330-D
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2393
Mailing Address - Country:US
Mailing Address - Phone:517-539-1216
Mailing Address - Fax:
Practice Address - Street 1:209 E WASHINGTON AVE STE 330-D
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2393
Practice Address - Country:US
Practice Address - Phone:517-539-1216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006619101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional