Provider Demographics
NPI:1922592328
Name:WINGFIELD, SUSANNAH BLISS
Entity Type:Individual
Prefix:MISS
First Name:SUSANNAH
Middle Name:BLISS
Last Name:WINGFIELD
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 1:6519 MANOR ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1909
Mailing Address - Country:US
Mailing Address - Phone:828-713-7567
Mailing Address - Fax:
Practice Address - Street 1:26300 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2019
Practice Address - Country:US
Practice Address - Phone:313-388-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102784104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker