Provider Demographics
NPI:1336257633
Name:TAYLOR, SUSAN (MSW CSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MSW CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15209 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49068-9570
Mailing Address - Country:US
Mailing Address - Phone:269-781-9119
Mailing Address - Fax:269-781-7872
Practice Address - Street 1:15209 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-9570
Practice Address - Country:US
Practice Address - Phone:269-781-9119
Practice Address - Fax:269-781-7872
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010215181041C0700X
MI4101005984106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7509107630OtherBLUE CROSS BLUE SHIELD
MI6801021518OtherLICENSE