Basic Information
| Provider Information | |||||||||
| NPI: | 1922246933 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OWEN | ||||||||
| FirstName: | SUE | ||||||||
| MiddleName: | RHODES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RHODES | ||||||||
| OtherFirstName: | SUE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 114 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 01/29/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| 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 | 1041C0700X | 6801014230 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |