Basic Information
Provider Information | |||||||||
NPI: | 1083921563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WITHERELL | ||||||||
FirstName: | SARAH | ||||||||
MiddleName: | LIETZOW | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D., LLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LIETZOW | ||||||||
OtherFirstName: | SARAH | ||||||||
OtherMiddleName: | JANICE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 101 E ALEXANDRINE ST | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3138315535 | ||||||||
FaxNumber: | 3133248782 | ||||||||
Practice Location | |||||||||
Address1: | 2751 E JEFFERSON AVE | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482074180 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3139933434 | ||||||||
FaxNumber: | 3139933421 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2010 | ||||||||
LastUpdateDate: | 03/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   | MI | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 103TC2200X | 6301015705 | MI | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.