Basic Information
| Provider Information | |||||||||
| NPI: | 1255906848 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUTTON | ||||||||
| FirstName: | CARSON | ||||||||
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| Credential: | BSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 42669 GARFIELD RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480381653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003953223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2021 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 247200000X | Y | Technologists, Technicians & Other Technical Service Providers | Technician, Other |
ID Information
| ID | Type | State | Issuer | Description | 1497760086 | 05 | MI | MEDICAID |