Provider Demographics
NPI:1164453114
Name:CONSIGLIO, SUSANNE E (RD)
Entity Type:Individual
Prefix:MS
First Name:SUSANNE
Middle Name:E
Last Name:CONSIGLIO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22811 GREATER MACK AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2021
Mailing Address - Country:US
Mailing Address - Phone:586-778-4877
Mailing Address - Fax:586-778-3004
Practice Address - Street 1:22811 GREATER MACK AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2021
Practice Address - Country:US
Practice Address - Phone:586-778-4877
Practice Address - Fax:586-778-3004
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIR00595403133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N39270OtherMEDICAN PIN