Provider Demographics
NPI:1578193363
Name:PRILL-WALLACE, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PRILL-WALLACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3785 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2433
Mailing Address - Country:US
Mailing Address - Phone:989-791-2455
Mailing Address - Fax:
Practice Address - Street 1:720 W WACKERLY ST STE 11
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2769
Practice Address - Country:US
Practice Address - Phone:989-832-2165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801099668104100000X
MI6801113743104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker