Provider Demographics
NPI:1902017767
Name:LEITMAN, SUSAN I (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:I
Last Name:LEITMAN
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 1:36880 WOODWARD AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0919
Mailing Address - Country:US
Mailing Address - Phone:248-258-1650
Mailing Address - Fax:248-647-1572
Practice Address - Street 1:36880 WOODWARD AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0919
Practice Address - Country:US
Practice Address - Phone:248-258-1650
Practice Address - Fax:248-647-1572
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F32547OtherBLUE CROSS BLUE SHIELD MI
MI0P15650Medicare ID - Type Unspecified