Provider Demographics
NPI:1194029314
Name:DANIELSON, SUSAN G (PSYD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:DANIELSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38807 ANN ARBOR RD
Mailing Address - Street 2:STE 9
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3896
Mailing Address - Country:US
Mailing Address - Phone:734-772-0148
Mailing Address - Fax:734-943-6051
Practice Address - Street 1:38807 ANN ARBOR RD STE 9
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150
Practice Address - Country:US
Practice Address - Phone:734-772-0148
Practice Address - Fax:734-943-6051
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-03
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014712103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H28818OtherBCBSM PROVIDER PIN
MIMI6823Medicare PIN