Provider Demographics
NPI:1942233861
Name:MATLAS, SUSAN G (LMSW, LMFT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:G
Last Name:MATLAS
Suffix:
Gender:F
Credentials:LMSW, LMFT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:GAIL
Other - Last Name:ABRUZZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28000 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-2468
Mailing Address - Country:US
Mailing Address - Phone:586-753-0405
Mailing Address - Fax:586-753-0404
Practice Address - Street 1:5111 AUTO CLUB DR
Practice Address - Street 2:#120
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2749
Practice Address - Country:US
Practice Address - Phone:313-583-0735
Practice Address - Fax:313-583-0751
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801015677104100000X
MI4101005550106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS06225Medicare UPIN
MIQ26426032Medicare ID - Type Unspecified