Provider Demographics
NPI:1396897450
Name:STACKPOOLE, SUSAN K (LMSW, CSW, BCD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:STACKPOOLE
Suffix:
Gender:F
Credentials:LMSW, CSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:248-601-9990
Mailing Address - Fax:248-601-9991
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-601-9990
Practice Address - Fax:248-601-9991
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010781841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical