Provider Demographics
NPI:1508409715
Name:KING, SUSAN LESLEY (LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LESLEY
Last Name:KING
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 SEMINOLE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-6536
Mailing Address - Country:US
Mailing Address - Phone:949-584-7554
Mailing Address - Fax:
Practice Address - Street 1:1601 GALBRAITH AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6479
Practice Address - Country:US
Practice Address - Phone:616-953-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001905A106H00000X
MI4101006694106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist