Provider Demographics
NPI:1588232896
Name:WILLACKER-BROWN, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:WILLACKER-BROWN
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 1:3201 ROCKCRESS CT
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-9690
Mailing Address - Country:US
Mailing Address - Phone:517-902-7443
Mailing Address - Fax:
Practice Address - Street 1:340 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1290
Practice Address - Country:US
Practice Address - Phone:517-902-7443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009304103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty