Basic Information
Provider Information
NPI: 1275963852
EntityType: 2
ReplacementNPI:  
OrganizationName: SUSAN GROSS PSYD PLLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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Mailing Information
Address1: 451 S ETON ST
Address2:  
City: BIRMINGHAM
State: MI
PostalCode: 480096524
CountryCode: US
TelephoneNumber: 2487214716
FaxNumber: 7342075326
Practice Location
Address1: 451 S ETON ST
Address2:  
City: BIRMINGHAM
State: MI
PostalCode: 480096524
CountryCode: US
TelephoneNumber: 2487214716
FaxNumber: 7342075326
Other Information
ProviderEnumerationDate: 11/19/2013
LastUpdateDate: 07/21/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: GROSS
AuthorizedOfficialFirstName: SUSAN
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: PSYD/OWNER
AuthorizedOfficialTelephone: 2487214716
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PSYD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700XE16510MIY193200000X MULTI-SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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