Basic Information
| Provider Information | |||||||||
| NPI: | 1841743655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DE LEON | ||||||||
| FirstName: | SUSANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | LLMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495034526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6169658200 | ||||||||
| FaxNumber: | 6169405366 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 CHERRY ST SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162357272 | ||||||||
| FaxNumber: | 6162350739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2016 | ||||||||
| LastUpdateDate: | 01/31/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.