Provider Demographics
NPI:1457386740
Name:SUSAN I LEITMAN, PHD, PC
Entity type:Organization
Organization Name:SUSAN I LEITMAN, PHD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:I
Authorized Official - Last Name:LEITMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-258-1650
Mailing Address - Street 1:36880 WOODWARD AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-0919
Mailing Address - Country:US
Mailing Address - Phone:248-258-1650
Mailing Address - Fax:248-647-1572
Practice Address - Street 1:36880 WOODWARD AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-0919
Practice Address - Country:US
Practice Address - Phone:248-258-1650
Practice Address - Fax:248-647-1572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301004071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
680F32547OtherBC/BS OF MICHIGAN
680F32547OtherBC/BS OF MICHIGAN