Provider Demographics
NPI:1679609853
Name:ASSIM, SUSAN CAROL (MS, LPC)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:CAROL
Last Name:ASSIM
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5279 WELCH LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9640
Mailing Address - Country:US
Mailing Address - Phone:517-522-3779
Mailing Address - Fax:
Practice Address - Street 1:323 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2120
Practice Address - Country:US
Practice Address - Phone:517-783-2732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401002767101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional