Provider Demographics
NPI:1790871259
Name:MALONEY, SUSAN A (PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:A
Last Name:MALONEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 LAGUNA DR.
Mailing Address - Street 2:
Mailing Address - City:WOLVERINE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390
Mailing Address - Country:US
Mailing Address - Phone:248-669-9569
Mailing Address - Fax:248-669-1925
Practice Address - Street 1:55 NORTH POND DR.
Practice Address - Street 2:SUITE 6
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390
Practice Address - Country:US
Practice Address - Phone:248-926-8532
Practice Address - Fax:248-669-1925
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010320103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent