Provider Demographics
NPI:1669613097
Name:HALL, SUSAN LESLI (MA, LPC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:LESLI
Last Name:HALL
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:MRS
Other - First Name:SUSAN
Other - Middle Name:LESLI
Other - Last Name:WHALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LPC
Mailing Address - Street 1:611 GLADSTONE DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-2818
Mailing Address - Country:US
Mailing Address - Phone:616-634-1262
Mailing Address - Fax:616-466-7678
Practice Address - Street 1:4670 FULTON ST E STE 101
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8409
Practice Address - Country:US
Practice Address - Phone:616-634-1262
Practice Address - Fax:616-975-3163
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-15
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009884101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional