Provider Demographics
NPI:1083921563
Name:WITHERELL, SARAH LIETZOW (PHD, LLP)
Entity Type:Individual
Prefix:DR
First Name:SARAH
Middle Name:LIETZOW
Last Name:WITHERELL
Suffix:
Gender:F
Credentials:PHD, LLP
Other - Prefix:MS
Other - First Name:SARAH
Other - Middle Name:JANICE
Other - Last Name:LIETZOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:101 E ALEXANDRINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2011
Mailing Address - Country:US
Mailing Address - Phone:313-831-5535
Mailing Address - Fax:313-324-8782
Practice Address - Street 1:2751 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4180
Practice Address - Country:US
Practice Address - Phone:313-993-3434
Practice Address - Fax:313-993-3421
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
MI6301015705103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program