Provider Demographics
NPI:1669901641
Name:BECKWITH, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BECKWITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 ROCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:LEONARD
Mailing Address - State:MI
Mailing Address - Zip Code:48367-3002
Mailing Address - Country:US
Mailing Address - Phone:248-628-7123
Mailing Address - Fax:248-628-7123
Practice Address - Street 1:2230 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:LEONARD
Practice Address - State:MI
Practice Address - Zip Code:48367-3002
Practice Address - Country:US
Practice Address - Phone:248-083-0619
Practice Address - Fax:248-628-7123
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF630287239320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities