Provider Demographics
NPI:1245628882
Name:MYS, SUE (LBSW,QIDP)
Entity type:Individual
Prefix:MS
First Name:SUE
Middle Name:
Last Name:MYS
Suffix:
Gender:F
Credentials:LBSW,QIDP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:MYS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LBSW,QIDP
Mailing Address - Street 1:35000 VAN BORN RD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-2458
Mailing Address - Country:US
Mailing Address - Phone:734-722-1000
Mailing Address - Fax:734-722-0368
Practice Address - Street 1:35000 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2458
Practice Address - Country:US
Practice Address - Phone:734-722-1000
Practice Address - Fax:734-722-0368
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802064401171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator