Provider Demographics
NPI:1164580460
Name:DETTLOFF, SUSAN E (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:E
Last Name:DETTLOFF
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24715 LITTLE MACK AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-3207
Mailing Address - Country:US
Mailing Address - Phone:586-777-9000
Mailing Address - Fax:586-777-0823
Practice Address - Street 1:24715 LITTLE MACK AVE
Practice Address - Street 2:STE. 200
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-3207
Practice Address - Country:US
Practice Address - Phone:586-777-9000
Practice Address - Fax:586-777-0823
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801033706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOQ26429-068Medicare ID - Type UnspecifiedPROVIDER NO.