Provider Demographics
NPI:1518080282
Name:SUPPLE-DIAZ, LINDA SUE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:SUE
Last Name:SUPPLE-DIAZ
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 1:5153 CANYON OAKS DR
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-7506
Mailing Address - Country:US
Mailing Address - Phone:810-229-8002
Mailing Address - Fax:
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:248-646-8645
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010338901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical