Provider Demographics
NPI:1376049502
Name:SHLEBAH, SURA R (LMSW)
Entity Type:Individual
Prefix:
First Name:SURA
Middle Name:R
Last Name:SHLEBAH
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 1:22720 MICHIGAN AVE STE 175
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2035
Mailing Address - Country:US
Mailing Address - Phone:313-338-6964
Mailing Address - Fax:
Practice Address - Street 1:6451 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2212
Practice Address - Country:US
Practice Address - Phone:313-945-8138
Practice Address - Fax:313-624-9418
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102173104100000X
MI6801108558104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker