Provider Demographics
NPI:1265525109
Name:GOTTLIEB, SUSAN JILL (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JILL
Last Name:GOTTLIEB
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 1:23800 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE #104
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-2560
Mailing Address - Country:US
Mailing Address - Phone:248-471-0785
Mailing Address - Fax:248-471-1406
Practice Address - Street 1:23800 ORCHARD LAKE RD
Practice Address - Street 2:SUITE #104
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-2560
Practice Address - Country:US
Practice Address - Phone:248-471-0785
Practice Address - Fax:248-471-1406
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301007337103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F33105OtherBCBSM