Provider Demographics
NPI:1972232122
Name:SISU MICHIGAN LLC
Entity Type:Organization
Organization Name:SISU MICHIGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER/ CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANYELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CAADC
Authorized Official - Phone:989-403-0192
Mailing Address - Street 1:1363 N GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48634-9759
Mailing Address - Country:US
Mailing Address - Phone:989-751-7854
Mailing Address - Fax:
Practice Address - Street 1:2222 W GRAND RIVER AVE STE A
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1604
Practice Address - Country:US
Practice Address - Phone:989-403-0192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty