Provider Demographics
NPI:1609104272
Name:BLAINE, SUSAN LYNN (LMSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:BLAINE
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 1:854 WASHINGTON AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-7141
Mailing Address - Country:US
Mailing Address - Phone:616-355-3926
Mailing Address - Fax:616-393-6651
Practice Address - Street 1:854 WASHINGTON AVE STE 330
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-7141
Practice Address - Country:US
Practice Address - Phone:616-355-3926
Practice Address - Fax:616-393-6651
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010792851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical