Provider Demographics
NPI:1730344581
Name:POTTER, SUSAN WHITEHEAD
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:WHITEHEAD
Last Name:POTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11080 HALL RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1511
Mailing Address - Country:US
Mailing Address - Phone:586-254-7200
Mailing Address - Fax:
Practice Address - Street 1:11080 HALL RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1511
Practice Address - Country:US
Practice Address - Phone:586-254-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000206237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
0E01107OtherBLUE SHIELD
MI540E00292OtherMICHIGAN BLUE SHIELD
0E01107OtherBLUE SHIELD