1316369937 NPI number — MR. JUSTIN DAVID PETRUSAK LMSW

Table of content: MR. JUSTIN DAVID PETRUSAK LMSW (NPI 1316369937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316369937 NPI number — MR. JUSTIN DAVID PETRUSAK LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUSAK
Provider First Name:
JUSTIN
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316369937
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9428 MCDOUGALL ST FL 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMTRAMCK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48212-3564
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-214-4019
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4756 CASS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48201-2357
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-577-4409
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801090356 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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